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13.855 White Rock Rd. btenc yc le Rancho Cordova, CA 95742 <br />(916) 351-0980 Enoorroarital <br />Date: 5/15/2019 <br />Time: 10:00 AM <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 <br />and 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 />Company Name: Vintage Pool Service & More Company Rep: Athena LaRue Company Address: 1780 E. Yosemite Ave. EPA ID # CAL 000 414 633 <br />Manteca, CA 95336 Signature: <br />Phone Number: 209-599-8300 Title: 71. <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />General Waste Description (Chemical <br />Constituent, Ph, WTC.) <br />Haz. <br />Class <br />AH <br />Waste <br />State <br />Code S/L # of <br />Cont, <br />Container <br />Type/Size <br />Total Waste <br />(gal / ft) <br />Total Waste <br />(pounds) <br />Disp <br />Meth Cost <br />Chlorine, Sodium Hypochlorite 8 5 5 gal 212 Ibs $296.80 <br />Processing Fee <br />$20.00 <br />Total Paid: <br />$316.80 <br />Date: SA <br />Method of Pymnt: Cash <br />itericycle Check-In Attendants Initials: <br /> Inv