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M! 4 4 11855 White Rock Rd. <br /> Stark cie Rancho Cordova, CA 95742 Date: 16110118 <br /> III (916) 351-098D <br /> Time: 84: g1jArn- <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the Stericycle Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> California State Regulations,and this quantity of waste does not exceed the specified limits for the type of waste being disposed. If this waste is later found <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Pacific Northwest Oil / Kents Oil <br /> Company Name: Company Rep: Lance Coleman <br /> Service <br /> Company Address: 3310 E Miner Ave. EPA ID# CAL 000 226 151 <br /> Stockton, CA 95205 Signature: <br /> Phone Number: 209-649-3867 Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp <br /> S/l COSY <br /> Constituent, Ph,WTC.) Class Waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> Paint NR L 24 1gal/1qt 18 $63.00 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv ilTotal Paid: $83.00 <br /> Stericycle Check-In Attendants Initials: Date: <br />