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i <br /> is <br /> �•' Ste icycje� ttgSS Wh1Y Reek Road <br /> En„ro v RanOto[oreow,.CA5S741 <br /> n'^^ntai soluucns (916)3Si-0980 Date: <br /> Time: <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 Sterlcycle Condmonaily Exempt <br /> Small quantity Generator Waste Acceptance Program.1 further certify that I am a Condglulally Exempt Small Quantity Generator as defined try 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 /> On <br /> to exceed small quantity limits or contain materials not accepted under this program I agree to complete a Waste <br /> befog waste menden and comply fou <br /> other state regulations as appropriate. With <br /> Company Name: I.A-y p,(I�fl I✓I� T <br /> Company Address: Company Rep: <br /> I�S6 N tJILSON 1ADAY EPAIDN <br /> sTo� -TCCA g5zos �A�ovoti3-4S6 <br /> ine Number: Signature: A� � <br /> LlC% 7"H- 1636 Title: oPB/Z <br /> U/Z Date: OK Oro ?JJ1$ <br /> TO BE COMPLETED BYSTERICYCLE CHECK-IN ATTENDANT <br /> General Waste Descripticn(Chemical Hat. At, State Sal n of coe;nne. Toral waste Total Waste Doo <br /> Constituent,Ph,WTC,) Class Waste Code #of. Type/site COSI <br /> Rf iTY .,ttPA C-,,2-.rs�rr�r�f9cl teal/tt) (pounds) Metn <br /> 2 s t ��k 5 cis �•00 <br /> 'rocessing Fee $2 o. <br /> nethod of Pymnt: cash Checldr Inv Total Paid p 2�-•do <br /> terityde Check-in Attendants Initials: Date: O `p <br />