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CleanEaftho 11855 White Rock Rd. <br /> Rancho Cordova,CA 95742 Date: 2/23/2022 <br /> (916)351-0980 <br /> Time: 1:00PM <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@goodwill-sjv.org <br /> Company Name: Goodwill Industries of SJV Company Rep: Terry Price <br /> Company Address: 129 S.Grant Street EPA ID# L 0173249 <br /> _- Stockton,CA 95202 Signature: f —� <br /> Phone Number: 559-545-5487 Title: j ate: 2—2 1 <br /> TO BE COMPLETED BY STERICYCLE CHECK-11NOTENDANT <br /> General Waste Description(Chemical Haz. AH State >k of Container Total waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code SQL Cont. Type/size (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 5 37 each 2 lbs $6.00 <br /> Compact Fluorescent Lamps UW S 42 each $52.50 <br /> h P 560 A s i � 0.a5 ib Pa. . <br /> Genn Dj7,:2-f,0o0,IX14 . • I G� v i ONle i3 Ito N).I . <br /> ?C i m cue r i 1 80414 11D.W110 �0.v q <br /> rw.' Ibv4f.m k ( &j}})am d,Od1b $0•'03 <br /> GGresCitf� <br /> —.1 S t 00"C.. C),I'b Ib 10,18 <br /> 1 b*M 1 601 We G, S a 0.19 Ib s©'a- <br /> uir ft- 4pule 1 1 5 ISO )?aCK5 0.31 lb 6='1.3 <br /> Processing t=ee $20.00 <br /> Method of Pymnt: Cash Check# Inv ITotal Paid: <br /> Clean Earth Check-in Attendants Initials: Date: ,x_o 3 <br /> ' -V / <br /> 9' <br /> l <br /> ll' <br /> if 'i <br />