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K.;fi 0,i ith 100,1. <br />-•171-1,1 <br />11855 White Rock Rd. <br />Rancho Cordova, CA 95742 <br />(916) 351-0980 <br />Date: 1/22/2022 <br />Time: 8:45 AM <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICATION <br />RECEIPT AND CERTIFICATION STATEMENT <br />To be completed by the generator: <br />- <br />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. bemachado4@verizon.net <br />Company Name: <br />Company Address: <br /> <br />Bob Machado Farms Company Rep: Bob Machado <br /> <br />22525 5 Airport Way EPA ID # CAL000405168 <br /> <br />Manteca, 'CA 953-37 - <br />209-988-2521 <br /> <br />_ <br />Phone Number: <br /> <br />Signature: <br /> <br />Title: <br /> <br />Date: <br />_ TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br />General Waste Description (Chemical <br />Constituent, Ph, WTC.) <br />Haz. <br />Class <br />AH <br />Waste <br />State <br />Code <br />S/L <br /># of <br />Cont. <br />Container <br />Type/Size <br />Total waste <br />(gal / ft) <br />Total Waste <br />(pounds) <br />oisp <br />meth Cost <br />Soil contaminated with Diesel Fuel NR S 1 2% g cc:616,04 220 lbs $ 42.1. We <br />_ <br />Processing Fee $20.00 <br />Method of Pymnt: Cash Cherk# Me) PI Inu Tntal Pali+ 11411.1 Ls • <br />Date: I -2 2.- 2.2. <br /> 0/2(at; <br />Clean Earth Check-In Attendants Initials: