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lean <br />Eafth <br />11855 White Rock Rd. <br />CRancho Cordova, CA 95742 <br />� (916) 351-0980 <br />Date: 5/12/2021 <br />Time: 8:30 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 5tericg a 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 />agproJect@sbcglobal.net <br />Company Name: Grewal's Gas &Liquor Company Rep: Rick Grewal <br />Company Address; 4100 E, Fremont Street EPA ID # CAL000296516 <br />Phone Number: <br />Stockton CA 95215 <br />209-986-0797 <br />Signature: <br />Title: �1 ivJAwf <br />TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />Method ofE <br />General Waste Description (Chemical <br />Constituent, Ph, WTC,) <br />Haz, <br />Class <br />AH <br />Waste <br />State <br />Code <br />5�l <br /># of <br />Cont, <br />Container <br />Type/size <br />'total Waste <br />(gal / ft) <br />Total Waste <br />(pounds) <br />oisp <br />Meth <br />Cost <br />Absorbent mixed with Motor Fuel <br />N R <br />S <br />3 <br />5 gal <br />90 lbs <br />$126.00 <br />MENEM <br />Processing Fee <br />$20.00 <br />(mnt: Cash Checkff <br />Ch4k_In Attendants Initials: <br />CdBD L1IDTAG TR � �-/ �5� <br />Inv <br />Total Paid* $146,00 <br />Date: � ,� , <br />