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COMPANY REP: , Athena LaRue <br />EPA ID#: CAL 0 14633 <br />DATE: //A ) — — <br />SIGNATURE: <br />TITLE: <br />ct <br />11855 WHITE ROCK ROAD er 111 StETTEWle. RANCHO CORDOVA, CA 95742 • <br />(916) 351-0980 <br />Date of Event: October 20, 2016 <br />Time: , 3:00 pmn <br />Informed: <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 requirement 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 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: Vintarie Pool Service & More <br />COMPANY ADDRESS: 1789 .E....yosemite Avenue <br />CITY, STATE, ZIP: Manteca (A 95336 <br />COMPANY PHONE: ( 209 ) 699-830Q <br />TO BE COMPLETED BY STERICYCLE CRE K-IN Al I ENDANT <br />GENERAL WASTE DESCRIPTION <br />(CHEMICAL CONSTITUENT. ETC.) <br />Chlorine <br />Objarine Ta_blets 8 <br />HAZARD A1-1 STATE Si 4 OF CONTAINER WASTE WT(LE) DISE. CLASS WASTE CODE 1. CONT TYPE/SIZE AMOUNT METH 8 4 5gal —f <br /> 1 5gal 44 <br />COST <br />216.32 <br />57,20 <br />rocessing Fee <br />EETROD OF PAYMENT: <br />20- <br />CASH CHECK C3 CHECK NO.,213-) 5 TOTAL PAID $ 293.52 <br />!TRICYCLE CHECK-IN ATTENDANTS INITIALS <br />DA I E D /I& <br />C-207 RE V U4/15 <br />CHECK-IN RECEIPT