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11855 WHITE ROCK ROAD <br />W • IP Stericycie° RANCHO CORDOVA, CA 95742 <br />(916)351-0980 <br />Date of Event: <br />Time: <br />Informed:. <br />Timm Participated: <br />Fc <br />oof? <br /> <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 />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 <br />under this program, I agree to complete a hazardous waste manifest and comply with other state regulations as appropriate. <br />COMPANY NAME: \jilt tlq i; 1 v & ,,,:Gre,-- COMPANY REP: A4--he pol 1 e, gu.L- fl 0 1 <br />COMPANY ADDRESS: ! 1::,IL ) IYO(-711/ /IC, A li..._ • EPA ID#: CAL OL);) / 1-1 69. '..,:.• <br />SIGNATURE: ...4„..,<-_,,c- ----7 6/7; __,..-' ,.., L—• ‘-- , t —7 <br />COMPANY PHONE: (2O) ii I -- A3ou TITLE: 1,--,,pk. P.._ tii3Oic.DATE: 2 k I t <br />TO BE COMPLETED CHECK-IN ATTENDANT BY STERICYCLE <br />.GENERA L WASTE DESCRIPTION <br />(CHEMICAL CONSTITUENT. Ph., ETC.) <br />HAZARD <br />CLASS <br />AH <br />WASTE <br />STATE <br />CODE <br />4 OF <br />CONT <br />CONTAiNER <br />TYPE/SIZE <br />WASTE <br />AMOUNT <br />,XT(Lii) DISR <br />METE{ <br />COST <br />Or 1 6r ny,L Tg„ \oi P A-6-,O I C <br />Ri i‘ni tut, . h•_., 9) MIME a 5 G a k H) C-". 4 111511111 <br />MEM <br />\ 6 <br />[ - u ; ', • A 4-, , .'-:;,,,411 TO; ftijA 1'14 'r • t..,, . , ! ... cl, ....,/ -f,,,. i 1 cm (-1 . <br />MI <br />El <br />le i <br />. <br />11111 <br />i..._ 111111=11111111 li 1-Th <br />r i r n j (:- i Y1 0 6 <br />111111111111111M0111111 <br />IIIIIIIIHIIIIIIMIIIIIIIIII III 111111111.11111111 <br />11111111111 11111 <br />2C) <br />METT-10 Vs OF PAY M N CASH 0 CHECK CHECK Na Z. LI 3 Ci TOTAL PAID S 2 r. <br /> <br />cTERIcYCI .E CHECK-IN ATTENDANTS TA T1NTT S DATE 2-1-1 7 <br />CITY, STATE, ZIP: Alarilp6a (_R- 1,s-33a9 <br />CHECK-1N RECEIPT PSC-207 REV 04P; 5