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1 <br /> 11855 White Rock Rd. <br /> CleanEad Rancho Cordova,CA 95742 Date: 10/7/2020 <br /> (916)351-0980 <br /> Time: 10:00 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 other <br /> state regulations as appropriate. ronsautosvc@comcast.net <br /> Company Name: Ron's Auto Service Company Rep: Ron Dahnke <br /> Company Address: 25533 N.Highway 99 Frontage Road EPA ID# CAL 000146 353 <br /> Acampo, CA 95220 Signature: 7 <br /> Phone Number: 209-366-2213 Title: 6tt) Date./ <br /> e,z'i2O <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp COSI <br /> Constituent,Ph,WTC.) Class Waste Cade SQL Cont. Type/Size (gal ft) (pounds) Meth <br /> Brake Grindings NR 5 1 5 gal 22 lbs $30.80 <br /> Floor Absorbent 6.1 S 1 15gal 33.6 lbs $47.04 <br /> I <br /> I <br /> I <br /> �I <br /> I Processin� e <br /> $20.00 <br /> VletbK6f Pym cash Check# Inv Total Paid: $97.84 <br /> 'icycle C k-In Attendants Initials: Date: �G� <br /> P-DIT CARD ENDING IN <br />