Laserfiche WebLink
'TOTAL PAID SL, 31) 11 <br />C1101 ••••••••• <br />DATE <br />i:ETI-E01) OF PAYMENT: CASH Q CILECK <br />CHECK-IN ATTENDANTS INITIALS .._ <br />CK NO. 17 <br />, <br />6 c. I 1835 WHITE ROCK ROAD <br />-Ste ric Ycl RAI\ICHO CORDOVA, CA 95742 <br />i6) :35 -0980 <br />Datc of Evctit 111.01 14- <br />Time. <br />Irtforrited: <br />Times Participated: <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br />TO BE BY GENERATOR: <br />[ certify that the following information is correct, and I have read and understand the requirements for participation in the <br />Stericycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I am a Conditionally Exempt <br />Small Quantity Generator as defined by Federal and California State regulations, and this quantity of waste does not exceed the specified <br />limits for the type of waste. being disposed. If this waste is later found to exceed small quantity limits or contain materials not accepted under this program, T agree to complete a hazArdous waste manifest and comply with other state regulations as appropriate. <br />) COMPANY NAME: 'I i i 11 ( .( t . <br />. <br />C)e._ V VI ( C:5 COMPANY REP: <br />X•'ANY ADDRESS: 1 1 .t.. ..... \ L Coljki'1.111 :,/ i . CPA rD#: J' LOO O LI ) L CI ts:._ (I :3 (r TY, STATE, ZIP: litA Cif 5i' , . <br />COMPANY PHONE: ('/A 4(('/A 4(LI 3 Ct <br />TO BE COMPLETED BY STERICYCLE CHECK-IN Al <br />GENERAL WASTE DESCRIPTION (:( T fk;TvIjCA I. CONSTIII IFNI; Ph . FTc.) <br />HAZARD <br />CLASS <br />Aft <br />WASTE STATE <br />CODE <br />St <br />I <br /># OF <br />aNNIT <br />COWFMNER <br />TYPE/SIZE WASTE <br />AMOUNT <br />, WT(LB) <br />. <br />DISP; <br />METH <br />COST 1 <br />, 1 <br />• I. i 1-1 I i i il i IC LOY 1 7If..4',/-7- <br />- <br /> "-7 -"3- ) P-9R0-4 n i ' 1 <br />--- -r---, <br />(...., <br />,'!,, 1. t..,-y) f e.____. ' -• - , <br />.--.--T f , ., „ , . , - , L )/ i. i ,... _...._____. ,,) - 17,:3 <br />Li 'II; -1(4 (4! — .. ..._ . <br />i • <br />J <br /> I-1 <br />.1 <br />.. b ) -,,,,,j- ,, i , bt, ..,.K...i..,(.: r ' k- • -. r 0 <br />„IV FT' <br />• • e , ..: . . t ..i. il'ev, <br />. ___..... - • - , • a <br />......__ <br />...... ._... .... <br />,... <br />, ."(. r" ;7)) Yll:k I t';'I <br />. .... _ .. — ,it <br />I <br />SIGNATURE: aft> <br />•TITLE: P *._(e) DATE: ("so_