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11855 White Rock Rd. <br /> 10 0,1 Sterolcyck Rancho Cordova, CA 95742 Date: 9/18/2019 <br /> (916)351-0980 <br /> Time: 8:00 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 I agree to complete a hazardous waste manifest and comply with <br /> other state regulations as appropriate. <br /> Company Name: Punta IRA Trust Company Rep: Oscar Punia <br /> Company Address: 5432 Shippee Lane EPA ID# CAC 003 033 140 <br /> Stockton, CA 95212 Signature: <br /> Phone Number: 213-245-4389 Title: ? Cate: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTEND NT <br /> General Waste Description(Chemical Haz. AH State SQL #of Container Total Waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) class Waste Code Cont. Type/Size {gal (poundsl Meth <br /> Oily Absorbent NR S Bagged 220 lbs $308.01) <br /> [Processing Pee $20.00 <br /> Method of Pymnt: Cash Check# ` , Ing Total Paid: $328.00 <br /> 5tericycie Check-In Attendants Initials: <br /> Date: r <br />