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DATE: <br />COMPANY NAME: Vi /iv/ <br />COMPANY ADDRESS: 1.1 C, • <br />CITY, STATE, ZIP: tt; t J 71 .f? (' <br />COMPANY PHONE: (7,064 <br />(.1 tiC COMPANY REP: HI A-421-14"4 <br />Cf ;COL/ ft 1/Z' EPA ID#: CAL-0(Y )Li/LIT43. <br /> 5 -3 ;31 SIGNATURE: <br />TITLE: <br />11855 WHITE ROCK ROAD <br />Stericyde' RANCHO CORDOVA, CA 95742 <br />(916)351-0980 <br />Date of Event: <br />.Tirae: <br />Informed: <br />Times Participated: <br />i1ii)ii <br />- <br /> <br />CONDITIONALLY CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />I 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 lam 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 <br />under this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br />TO BE COMPLETED BY STERICYCLE CHIr.C1C-IN ATTENDANT <br />GENERAL WAS fE DESCRIMON <br />(CHEMICAL coNsTrruarr Ph., ETC HAZARD <br />CLASS <br />AH <br />WASTE <br />STATE <br />CODE <br />St <br />L <br />r OF <br />CONT <br />CONTAINER <br />TYPE/SIZE <br />, WASTE <br />AMOUNT <br />WT(LB) DIM <br />METH <br />!" <br />COST - <br />L... _______i 5<01 /034 ?5„(e. 1 1 1 <br />--;:icklil,L, ill [Wry --- . , <br />i r 1---) i .i.,... t •' -,' ...- <br />ft 7/ <br />e <br />e - ' ' -1 ( 1 ,, .., 4 - if, , LC' v 1 it...-4_ , ed .fi is, . 1 - <br />. <br />frill fl e t ." <br />_ .... --, <br />I -- <br />. . <br />l <br />' <br />0 - <br />_ <br />ME 01) OF PAYMENT; CASH Cl CHECK tit CHECK NO. 255C/ <br />STERICYCLE CHECK-IN ATITENDAN 3 INITIALS 5A <br />'SC-W7 RSV 04/15 <br />TOTAL PAID S Eri; <br />DATE <br />CHECK-IN RECEIPT