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rea ' 1 I +:* I ' N C i-1 f -V, ,) 0 ??.0 70 Ttl Ip;) ted corm urroNALLY cxicmi PT SMALL QUANTITY GENERATOR WASTE CHECK -EN RECF,EPT AND CERTIFICATION STATEMENT TO BE COMPLETED BY GENERATOR: I certify that the following irifataiation is correct, and I have read an. d understand the requiretiltatS fbr participation in the cycle Conditionally Exempt Small Quantity Generitor Waste Acceptance Program. I further certify that [am a Conditionally Exempt .1 Quantity Generator as defined by Federal and California State regulations, and this quantity of waste does not exceed the specified 3 for the type of waste being disposed.. If this waste is later found to exceed small quantity limits or contain materials not accepted this program, I agree, to complete a hazardous waste mnuifest and comply with other state regulations as appropriate. :PANY NAME: PAM' ADD RESS: , STATE, ZIP: .PANY PONE: ) 5 '''c COMPANY R v)(/) )te._ EPA f014: ten(?; At- 64:7-3k1-:--C: ee. EP: P-(14 "(41- q 913 SIGNATURE: Ioq (/ 34,31.) VTLE: DATE: TO BE COMPLETED BY STERICYCLE CEIECK4NATTENDANF sttm. ArAs t 4:- DE.:1- RIZ" 'TON HAZARD ICALCONSI TrUlaqT,Pti. CL(4J CLASS AH WASTE STATE CODE 'Si L. *OF corn- CaNTAINER TYPE/SECS , WASTE AMOUNT WT(LB) DISF MET/1 COST F \' n'l el: <:)TI atY1 ( 1 i)' W i2 Li 1 .4e )1 ....., * 1.1 . __. — i _ Lio..53, ......._ . !\.-c cilL4-5-11" , . _ _. _ . . ..., . .., . „..---, , ....2...: i— -74. i 4-:'<vt', Li ) ,',A.• k.••• J--••-•-• :\ . ''' • ------ __ ___ _____________ .. ____ • - - • ___ ____ • ,., . — _ _. - ... ....._ - .., — :.- -,i ---7 . - r . Li,,,,• -- I I • — _ - 1 ..........-- ---- — ts-A t :;f1itK it (.:Et 4.:K Nrcg------) fiu-d