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11855 White Rack Rd. <br /> C;3�eanEafth Rancho Cordova,CA 95742 Date. 7/29/2020 <br /> (936) 351-0980 <br /> Time: <br /> R: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 /> l certify that the following information is correct,and I have read and understand the requirements for particllsation in the Stericycle Conditionally Exempt <br /> Small Quantity Generator Waste Acceptance Program.I further certify that l 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 Omits for the type of waste being disposed.If this waste is later found <br /> to exceed small quantity limits or contain nmatermis not accepted under this program l agree to complete a hazardous waste manifest and comply with other <br /> state regulations as appropriate. <br /> Company Name. Fremont Plaza Ace Hardware Company Rep-. Evill Stoerrner <br /> Company Address: 2060 E.Fremont Street EPA ID# CAL 090 455 520 <br /> Stockton, CA 95205 Signature: _ <br /> 209-612-5573_ _ Title: �' � Date: <br /> TO 8E COMPLETED RIP STERICYCILE CHECK-IRI ATT1ENDAly I <br /> r General Waste Description(Chemical State of Container € Totaliflaste — Tanta!Waste — ©sp <br /> Constituent,Ph,WTC.p Class Waste Coale 5/E Cant �yFe/size l (gallft) (pounds) Math� CL�SL <br /> T°- crescent Tubes 4' x 36& � ��- � <br /> 18 UWi S 54 Boxed � 288` � $43.20 <br /> _ <br /> Pipe Threader Cutting Oil <br /> .- R L 1 1 Gal 1 Gal $8.25 <br /> Latex Paint Colorant empty) NR _._. __l L- 16 CK. 4 Gal l N/C <br /> Mi8c. Spill Cleanup Supplies f <br /> absorbant paper tov�rels I NR ; 5 1 1 Gal 1 lbs $1.40 i <br /> Spray Paint Canisters (empty <br /> or unused2.1 f {i S 12. Cit. 3 lbs - $12.60 <br /> f i <br /> i <br /> i <br /> — <br /> ............... <br /> E <br /> Processing Fee $20-00 <br /> Method of Pymnt: Cash Check# �yl/ Inv [Total Paid: $85.45 <br /> Stericycle Check-!n Attendants Initials: -_-_---._.___ ----•_-..- , .-- --__-- ®ate: <br />