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TO BE COIVLPLETED BY STER1CYCLE CHECK-IN Al 1 ENDANT GENERAL WASTE DESCRIPTION HAZARD Ax STATE S/ # OF I (CHEMICAL CONSTITUENT. Ph.. ETC.) CLASS WASTE CODE I, CONT <br />1 UM KW Atio:±L. a <br />Ltic\_ Ch\ur,n€,/ <br />COST <br />21(0. 0(0 <br />(0.6 <br />PrDa55in4 <br />CONTAINER WASTE WT(LB) TYPE/SIZE AMOUNT <br />qc)to <br />DISR <br />METH <br />/g55 WitITE ROCK ROAD <br />.• Sterkyde° RANCHO CORDOVA, CA 95742 41) 9 <br />(916) 351-0980 <br />Date of Event: <br />Tzlle: <br />Informed: <br />Times Participated: <br />:3110/17 <br /> <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTIFICATION STAIEMENT <br />TO BE COMPLETED BY GENERATOR: <br />I certify that the followine 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 Conftonally 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 smart quantity limits or contain materials not accepted <br />under this program, I wee to complete a hazardous waste margest and comply with other state regulations as appropriate. <br />COMPANY NAME: V V3 ?COMPANY REP: A-1(1 i_rIA <br />COMPANY ADDRESS: L7 EPA In-oh 44 1 cnry, STATE, ZIP: irtf,d cis?, )5(c , SIGNATURE: <br />COMPANY PHONE: (701) TITLE: SuraA115 011 DATE: 5 • 10 • I <br />METHOD OF PAYMENT: CASH C,T_-_,CK 'kg CHECK NO. <br />s IERICYCLE CHECK-IN ATTENDANTS INITIALS l4r <br />PSC-207 REV 04/IS <br />TOTAL PAID S (4 2— - 510 <br />DATE <br /> 31047 <br />CHECK-IN RECEIPT