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°�, 11855 White Rock Rd. <br />00 V �st6cycle Rancho Cordova, CA 95742 Date, 1/2/2020 <br />" 916 351-0980 <br />Time, 3:30 PM <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 <br />other state regulations as appropriate. <br />Company Name; Naglee Burl< Irrigation District Company Rep: Robert Mehlhaff <br />Comnanv Address: 4600 S. Tracy Blvd, STE. 114 EPA ID # CAL 000 360 640 <br />Phone Number; <br />I racy, LH y5� <br />209-835-3z3L <br />Total Paid: <br />Method of Pymnt; <br />Stericycle Check -In Attendants Initials: <br />