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• • 11855 WHITE ROCK ROAD <br />• Stericycie. RANCHO CORDOVA, CA 95742 11,111 <br />(916) 351-0980 <br />Date of Event: October 5, 2016 <br />Time: . I :30DM <br />Informed: <br />Tunes Participated: <br /> <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 />Stan cycle Conditionally Exempt Small Quantity Generator Waste Acceptance Program. l 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: Vintage Pool Service & More <br />COMPANY ADDRESS: 1780 E. Yosemite Avenue <br />CITY, STATE, ZIP: Manteca, CA 95336 <br />COMPANY PHONE: ( 209 ) 599-8300 <br />COMPANY REP: Athena LaRue <br />EPA m#: CAL 000414633 <br />SIGNATURE: ,okyikaiA, <br />TITLE: jiam.a. DATE: rpiti <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />(CHEMICAL CONSTITUENT, Ph, ETC.) <br />HAZARD <br />CLASS <br />Aft <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 />Chlorine 8 4 5gal 177.6 230.88 <br />Calcium Chloride 8 1 5ga1 9 11.7 <br />f Dichloro Granules 9 1 5gal . 29.84_,D8,74j <br />_ .. . <br />_ <br />Processing_Fee 20- <br />_ <br />METHOD OF PAYMENT: CASH 0 CHECK AL CHECK NO. <br />STERICYCLE CHECK-IN ATTENDANTS INITIALS C <br />PSC-207 REV 04/15 <br />TOTAL PAID $ 3Q1 <br />DATE (y, -5776-- <br />CHECK-IN RECEIPT