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CleanEaftho <br /> 11855 White Rock Rd. <br /> Rancho Cordova,CA 95742 Date: 2/23/2022 <br /> (916)351-0980 <br /> Time: 1:OOPM <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 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(agree to complete a hazardous waste manifest and comply with other <br /> state regulations as appropriate. tprice@goodwiil-sjv.org <br /> Company Name: Goodwill Industries of SJV Company Rep: Terry Price <br /> Company Address: 129 S.Grant Street EPA ID# _�AL900173249 <br /> Stockton,CA 95202 Signature: f — <br /> Phone Number: 559-545-5487 Title: j ate: 2_2_3 <br /> TO <br /> — <br /> TO BE COMPLETED BY STERICYCLE CHECK-11NOTENDANT <br /> General Waste Description(Chemical Haz. All State #of container Total waste Total Waste oisp <br /> Constituent,Ph,WTC.) Class Waste Code SQL Cont. Type/sae (gal/ft) (pounds) Meth COSI <br /> Fluorescent Tubes,4' UW S 92 each 368 Ift $55.20 <br /> Fluorescent Tubes,8' UW S 17 each 136 Ift $20.40 <br /> Paint 6.1 L 1 1 gal 0.25 gal $3.50 <br /> Paint 6.1 L 2 2 qt 1 gal $3.50 <br /> Propane Tanks 2.1 S 2 2 qt empty $3.00 <br /> Aerosol Cans 2.1 S 17 each empty 6 lbs $8.40 <br /> LED Light Bulbs UW ST 37 each 2 lbs $6.00 <br /> Compact Fluorescent Lamps UW S 42 each $52.50 <br /> h 0179560M .1 S t 441e O-Z To. 3s <br /> cwo D52%0o0.(igs Gt DH12 i3 Ito N). a. <br /> Fit W 1 %Htc 6.03 1 b �0.o q <br /> roui�}IF ibv+ttf>1 1 It ` i %He- 6.0a\lo i;o,,o3 <br /> GGtca tfe 1e,1 1 eo"Ic- C),lb ib Z Ur 18 <br /> I Mend 1501 We 6.1 101 0.1q Ib <br /> u im1 r ft- 4pule6 30 PaeKs 10.31 00 6 b '13 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Invt Total Paid: <br /> Clean Earth Check-in Attendants Initials: Date: _17 ,;Z;;? <br /> I <br /> i <br /> i <br />