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vm 11855 White Rock Rd. <br /> jilij n Earth Rancho Cordova,CA 95742 Date: 5/12/2021 <br /> 1 (916) 351-0980 <br /> Time: 8:15 AM A <br /> CtADITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be completed by the generator: <br /> certify that the following information is correct,and I have read and understand the requirements for participation in the Stericycle Conditionally Exempt <br /> nail Quantity Generator Waste Acceptance Program.I further certify that I am a Conditionally Exempt Small Quantity Generator as defined by Federal and <br /> alifornia 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 /> 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. )steel@spcfuels.com <br /> )mpany Name: Stockton Petroleum Company Rep: Jason Steel <br /> :)rnpany Address: 1905 Navy Drive EPA ID# CAH111000965 <br /> Stockton, CA 95206 Signature: .r 2-� <br /> lone Number: 209-462-8707 Title: e�2. Date: 07 <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> ieneral Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Dlsp <br /> Constituent,Ph,WTC.) Class Waste Code Sal Cont. Type/Size (gal/ft) (pounds) Meth Cost <br /> oorSweep NR S 1 Pail 10lbs $14.00 <br /> japers/Socks NR S 1 Pail 10lbs $14.00 <br /> iii"ater Based Exterior)* PC L 2 Pails 55 lbs N/C <br /> 'a.. <br /> -Care Item <br /> -ocessing Fee $20.00 <br /> ethod of Pymnt: Cash Check# Inv Tota! Paid: $48.00 <br /> ericycle Check-In Attendants Initials: t Date: <br />