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CleanEa�h <br /> 11855 White Rock Rd. <br /> Rancho Cordova, CA 95742 Date: 10/21/2020 <br /> (916) 351-0980 <br /> Time: 8:15 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 /> 5mall Quantity Generator Waste Acceptance Program.I further certify that I am a CondAlonally 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. jon.ogilvie@gcrtires.com <br /> Company Name: GCR Tires and Services Company Rep: Jon Ogilvie <br /> Company Address: 4336 Pock Lane EPA ID # CAL 000 404 901 <br /> Stockton, CA 95206 Signature: [? <br /> Phone Number: 209-983-9495 Title:Il. Date/1�). <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Naz AH State #of Container Total waste Total Waste wisp <br /> Constituent,Ph,WTC.) Class Waste Code 5/L Cont. Type/Size (gal/ft) (pounds) Meth COSI <br /> Ci Mat Filter Pack 6.1 L 1 1 gal 1 gal $8.25 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $28.25 <br /> Stericycle Check-In Attendants Initials: Date: — <br />