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I t55 wilri-F, ROCK ROAD Date of Event: November 16, 2016 SteriCyCle. RANCHO CORDOVA. CA 9S742 Tii= , 9c 30arn 0 * * (916)351-0980 Wormed: <br /> <br />Times P'articipaiock <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED 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 />Milts for the type of waste being disposed. /f 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 stale regulations as appropriate. <br />COMPANY NAME: Vintage Pool Service & More <br />COMPANY ADDRESS: 1780 E. Yosemite Avenue <br />CITY, STATE, ZIP: Mant9sp, CA 95336 • <br />COMPANY PHONE: ( 209 ) 599-8300 <br />COMPANY REP: Athena LaRue <br />EPA ID#: CAL0)19414633 <br />SIGNATURE: Z' <br />TITLE: .5k) Pei_vto(2_ DATE: <br />TO BE COMPLETED BY STERICYCLE CHECK-IN Ai IENDANT <br />GENERAL WASTE DESCRIPTION <br />(CHEMICAL CONSTITI TNT, Ph. FTC.) <br />HAZARD <br />CLASS <br />AH <br />WASTE <br />STATE <br />CODE <br />S/ <br />1. <br /># OF <br />CONT <br />CONTAINER <br />TYPE/SIZE <br />WASTE <br />AMOUNT <br />WT(LB) DISE'. <br />METH <br />COST <br />Chlorine Tablets 5.1 5 5gai 218.4 305.7 <br />i • <br />, , <br />I_ i" i <br />(-- <br />Processin• Fee 20- <br />.4 <br />METHOD OF PAYMENT: CASH CHECK le( CIJECK NO. 2315 _ <br />STERICYCLE CHECK-IN ATTENDANTS INITIALS <br />TOTAL PAID $ 326.76 <br />DATE ryz(d <br />CHECK-IN RECEIPT 'SC-2O7 REV 04/15 <br />