Laserfiche WebLink
;ENERAZ., WASTh DESCRWITON HAZARD <br />1130.1CM, CONSTITUENT. L. ETC) CLASS ; <br />510111.1./tiff <br />p <br />14 tAtrirt . <br />. ' <br />TROD OF PAYMENT: <br />' <br />CaTECK CTI 70° TOT PAI <br />i-1,Z41)1',..N -C.".;;F TiAL <br />D7,EIPT <br />• <br />1 g 5 5 W1411 fl OcTK ROA j) <br />RANci-fo cou.LxivA, cA. <br />G, <br />(9 6) 1`) I -0980 <br />Dam of Eveclt <br />flint <br />Informed <br />Times Prirticipated <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTIFICATION. STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />1 <br />I certify that the following information is correct, and I have read and understand the requirements for participation in the <br />tericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. t further certify that Earn a Conditionally Exempt <br />matt Quantity Generator as defined by Federal and California State regulations, and this qmarity of waste does not exceed the specified <br />nits for the type of waste being disposed_ If this waste is later found to exceed small quantity limits or contain materials not accepted <br />ider this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br />1 ,-i i (OO 5'-ef-VC Ce-' :3MPANY NAME: 1i 1. <br />:)MPANY ADDRESS I <br />TY, STATE, ZIP: 'vlf. /111)32,63 ,„ .5 6-2 • <br />3 IVXPANY PHONE: Jgg.' ',5-3(-' <br />COMPANY ItEP: Mem La ktic <br />EPA iDg: <br />SIGNATURE: ft <br />TITLE: /ewt 7—DATE: <br />TO B1 COMPLETED BY S I ERICYCLE CITF.CK-IN ATTENDANT