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11155 White Rock Rd. <br /> ean E aft Rancho Cordova, CA 95742 Date: 9/15/2021 C p N (916) 351-0980 <br /> Time: sod® Am <br /> CON MT NALLY EXEMPT SMALL QUANT11TV GENERATOR WASTE CHECK4N AND CERTmCATi�if� <br /> RRC CPT AND C ERTff1CATi®N 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 Clean Earth 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. barb.mcdermott@am.jll,com <br /> Company Name: G&I X Stockton Commerce GP, LLC Company Rep: Barbara McDermott <br /> Company Address: 3255 W. March Lane,Suite 105A EPA ID# NCO03 94 <br /> Stockton, CA 95219 Signature: <br /> Phone number: 209-993-3212 Title: Date. <br /> O BE COMPLE7ED BY ST[ERICVCLE CHECK4N ATTENDANTi <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) Class Waste Code S/L Cont. Type/Size (gal/ft) (pounds) Meth <br /> Used Coolant NR L 1 5 gal 3 gal $5.00 <br /> Rags Contaminated with Diesel Fuel NR 1_1 Bag 1 lb $1.40 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv <f C Total Paid: $26.40 <br /> Clean Earth Check-In Attendants Initials: Date: Z' �� <br />