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11855 White Rock Rd. <br /> CleanEafth 4 Rancho Cordova, CA 95742 2 date: <br /> (916)351.0980 <br /> CONDITIONALLY EXEMPT SMALL QUANTITYGENERAT OR WASTime:me° <br /> TE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> Tobe completed by the generator: <br /> I certify that the following information is correct,and I have read and understand the requirements for <br /> Small Quantity Generator Waste Acceptance Program.I further certify that I am a Conditionally Exempt small Quant <br /> ity California State Regulations,and this quantity of waste does not exceed the specified limits for the type of waste being disposed,If thwaste Is later found to <br /> participation in the Sterieyele Conditionally Exempt <br /> exceed small quantity limits or contain materials not accepted under this program I agree to complete a hazardous wast as defined by Federal and <br /> is <br /> state regulations as a e manifest and comply with other <br /> Company Name: appropriate, <br /> x <br /> Company Address: �� - Company Rep: <br /> f - EPA ID# l c <br /> Phone Number: Signature: <br /> Title: <br /> TO BE COMPLETED By STERICYCLE CHECK- `J Date: <br /> General Waste Description(Chemical IN agTTE1y®�RNY <br /> Constituent,Ph,IN'fC.) Haz. AH state Code #of <br /> Class Waste S/L Container Total Waste Total Waste Disp <br /> Cont. Type/Size (gal/ft) <br /> (pounds) Meth Cost <br /> xessing Fee <br />:thod of Pyinnt: cash <br /> ricycle check-h Attendants Initi initials!ecic# ,„v <br /> Total : <br /> Date: r <br />