Laserfiche WebLink
a$0 11855 White Rock Rd. <br />0 00 Stericycli Rancho Cordova, CA 95742 Date: 1/3/2020 <br />(916) 351-0980 <br />a u I fm <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 />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 Burk Irrigation District Company Rep: Robert Mehlhaff <br />Company Address: 4600 S. Tracy Blvd. STE. 114 EPA ID # CAL 000 360 640 <br />Tracy, CA 95377 Signature: 1::e�ar,.. vlldL <br />Phone Number: <br />209-835-3232 <br />Title: fi,., <br />ra. <br />Date: //V/q,q <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />Method of Pymnt: Cash Check# � 93Ye <br />General Waste Description (Chemical <br />Constituent, Ph, WTC.) <br />Haz. <br />Class <br />AH <br />Waste <br />State <br />Code <br />S / <br /># of <br />Cont. <br />Conta n, a <br />ype/Size <br />Total Waste <br />(gal Jft) <br />Total Waste <br />(pounds) <br />Disp <br />Meth <br />COst <br />Motor Oil <br />NR <br />L <br />1 <br />55 gal <br />$11.00 <br />Processing Fee <br />$20.00 <br />% Inv <br />Total Paid; $31.00 <br />Stericycle Check -In Attendants Initials: <br />Date: � 63 1� o <br />