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��°* 11855 White Rock Rd. <br /> �� "" , �@� c Rancho Cordova, CA 95742 Date: 1f�l1llz41 <br /> (915) 351-4980 <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 under.tar-,j ti•,e requirements fos participat;on in the 5tericycle Conditionally Exempt <br /> Small Quantity Generator waste Acceptance Program.I further certify that!am.: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 to the type of\waste being disposed,1f ih!5 waste is later found <br /> to exceed small quantity limits or contain materials not accepted undur tNti p-ogram I agree 4c r-ompletr a hazardous waste manifest and Comply with <br /> other 5,�Ete regulatlo!zs as appropriate. <br /> Company Name: Punla IRA Trust Company Rep: Oscar Punla <br /> Company Address: P.D. Box 8454 EPA ID 4 AC 003 433 140 <br /> Stockton, CA 95209 Signature: I <br /> T <br /> Phone Number: (213)245-4389 Title: lu k "e? Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IIS ATTENDANT <br /> General Waste Description(Chemical Haz. AH State Cf Container total waste Total Waste 01sp Cost <br /> Constituent,Ph,WTC.} Glass waste Code 5jt Cont. tvs%elSiae !gal l ft; (pounds) Jle[I, <br /> AbSorbant NR S 1'0 Bags 220 lbs $308.00 <br /> Processing Fee <br /> Method of Pymnt: Cash Check# Inv ITotal Paid: $328.00 <br /> 5tericycle Check-In Attendants Initials: a r f7ate: ' <br />