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11855 White Rock Rd. <br /> Rancho Cordova,CA 95742 Date: 7/29/2020 <br /> ,C(eanEad (916)351-0980 <br /> Time: 9:00 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: 11 <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. <br /> Company Name: Fremont Plaza Ace Hardware Company Rep: Bili Stoermer <br /> Company Address: 2060 E.Fremont Street EPA ID# CAL 090 455 520 <br /> Stockton, CA 95205 Signature: <br /> Phone Number: 209-612-5573_ _ Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of container Total Waste — Total Waste o sp l — <br /> Constituent,Ph,WTC.) Class i Waste Code SQL Cont. Typesize (gal/ft) (pounds) Meth Cost <br /> r'orescent Tubes 4'x 36& _ <br /> 18 UW S 54 Boxed 288' $43.20 <br /> Pipe Threader Cutting Oil NR L 1 1 Gal 1 Gal $8.25 <br /> Latex Paint Colorant(empty) NR L 16 Qt. 4 Ga! N/C <br /> Mitc.Spill Cleanup Supplies <br /> NR 5 1 1 Gal 1 lbs $1.40 <br /> (absorbant, paper towels) <br /> Spray Paint Canisters (empty <br /> or unused) 2.1 S 12 I Qt. 9 lbs $12.60 <br /> J <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# y�� _ Inv Tota! Paid: $85.45 <br /> Stericycle Check-In Attendants Initials: �/ —� -- Date: <br />