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11855 White Rock Rd. <br /> leERancho Cordova, CA 95742 Date: 9/23/2020 <br /> Canad ,i 4 <br /> (916) 351-0980 <br /> Time: 8:30 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the Stericycle Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program.I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> 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 <br /> to exceed small quantity limits or contain materials not accepted under this program 1 agree to complete a hazardous waste manifest and comply with other <br /> state regulations as appropriate. avigil@sicemeteries.com <br /> Company Name: San Joaquin Catholic Cemetery Company Rep: Albert E. Vigil <br /> Company Address: 719 E. Harding Way EPA ID# CAL 000 272 273 <br /> Stockton, CA 95205 Signature: <br /> Phone Number: 209-466-6202 Title: n';, : —L, Date: ► _ kY <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Dlsp <br /> Constituent,Ph,WTC.) Class Waste Code S/L Cont, Type/Size (gal/ft) (pounds) Meth Cost <br /> I <br /> Thompson's Water Seal 6.1 L 1 50 gal 15 gal $123.75 <br /> Fluorescent Tubes, 4' UW S 12 48' $7.20 <br /> Motor Oil NR L 1 5 gal 5 gal N/C <br /> Weed Killer 6.1 L 1 2.5 gal 0.5 gal $4.12 <br /> [Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv G Total Paid: $155.07 <br /> Stericycle Check-In Attendants Initials: Date: €C9_IVED UP 9- 3 2920 <br /> wl � <br /> ARD ENDING IN <br />