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es 11855 WHITE ROCK ROAD Date of Event: <br />0 0 Stericycle* RANCHO CORDOVA, CA 95742 Time: *it" (916) 351-0980 Informed: <br />limes Participated: <br />AuOuSt 3. 2016 <br /> <br />, 10: Oam <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 an 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 COMPANY REP: Athena LaRue <br />COMPANY ADDRESS: 1780 E. Yosemite Avenue <br />CITY, STATE, ZIP: Manteca, CA 95336 <br />COMPANY PHONE: ( 209 ) 599-8300 <br />EPA ut#: CAL 00 14633 <br />SIGNATURE: <br />TITLE: 00) KR.41-4-_, ciDATE: <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />ja-MMICAL CONSTITUENT, Ph., ETC-) <br />HAZARD <br />CLASS <br />AN <br />WASTE <br />STATE <br />CODE <br />Si <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 Tablets 5.1 2 5021 50,41 7057 - <br />Conditioner/ Cyanuric Acid 8A 1 5gal 10 13- <br />Clarifier 6.1 1 5gal 34.21 44.47 <br />Chlorine 8 5gal 47.21 66.09 <br />Processing Fee 20 <br />METHOD OF PAYMENT: CASH U CHECK 0 CHECK NO. <br /> <br />TOTAL PAID $ 214.13 <br /> <br />4:TE1I ICY CLE CHECK-IN ATTENDANTS INITIALS <br /> DATE <br />PSC-i07 REV 04/15 <br /> øq <br />CHECK-IN RECEIPT <br />061