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COMPANY REP: <br />EPA ID#: <br />SIGNATURE: <br />111 LE: DATE: gLik. <br />___.....--". <br />0 0 e 6 0 o * <br />11855 WHVIE R( iil; Rt.-% D <br />stericycle• RANCHO CORD( )vA, ( ,\ 95742 <br />(916)351-0980 <br />Date of Event: <br />Time: -, <br />..-• , <br />Informed: 71. <br />Times Participated: <br />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 />Sterieyele Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I ant 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 lin- the type of waste beirtn disposed. lf 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 />COMPANY NAME: <br />COMPANY ADDRESS: <br />CITY, STATE, ZIP: <br />COMPANY PHONE: <br />TO BE COMPLETED BY SI ERICYCLE CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />(CHEMICAL CONSTITUENT. Ph_ ETC.) <br />HAZARD <br />CLASS <br />AEI <br />WASTE <br />STATE <br />CODE <br />S/ <br />L <br /># OF <br />CONT <br />CONTAINER <br />TYPE/SIZE <br />WASTE <br />AMOUNT <br />WT(LB) DISP: <br />METH <br />COST <br />„ . . . ..- <br />• ; <br />' <br />, <br />— <br />- <br />-T-- <br />--I H <br />• <br />-I. <br />• <br />, <br />_ ..,„.......— _ <br />--- <br />METHOD OF PAYMENT: CASH 0 CHECK 0 CHECK NO. _ • TOTAL PAID $ <br />STERICYCI:E CHECK-IN ATTENDANTS INITIALS 5`A- <br />DATE <br />q_i 2.17 <br />CHECK-IN RECEIPT PSC-207 REV 04/15