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2185 White R�__ <br /> S eric cl Rancho Cordova,CA 95742 <br /> (916)351-0980 Date: <br /> Erov�rartirMPs�t�ni Sotut,on _ <br /> Time: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFiCATION STATEV1E'NT <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.l 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: /A1 &41tj j I`�/�AR,T Company Rep: <br /> Company Address: 1 X56 N rAQI L50 fly EPA ID # GA J_0()() ti 9 <br /> STG.-1fv"TON 4 CA C152-0-6 Signature: <br /> Phone Number: L,OC6.. zU 4- j 6 36 Title: OPCl2 v <br /> TO BE COMPLETED BYSTERICYCL£ CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code S/L Cont. Type/size (gal/ft) (pounds) Meth Cost <br /> K 1 i'r'l Go► tirwrna�ec! r/�. S <br /> vJ Tu>o n Z rcts� 5 Lbs • DtrJ <br /> a <br /> FWV U8 zap <br /> '°F T <br /> 'rocessing Fee ZO <br /> Aethod of Pymnt: Cash Check# InvTota)P <br /> tericycle Check-In Attendants Initials: Date: '' '— <br />