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11855 White Rock Rd. <br /> Rancho Cordova, CA 95742 Date: 3/9/2022 3 <br /> CleanEafth -., <br /> (916)351-0980 ` <br /> Time: 8:00 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 /> 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. gmoez1983luz@gmail.com <br /> Company Name: Ramirez Body Shop Company Rep: Luz Gomez <br /> Company Address: 1200 N Filbert Street EPA ID # CAL000453194 <br /> Stockton, CA 95205 Signature: <br /> Phone Number: 209-810-8756 Title: Date: <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State S/L #of Container Total Waste Total Waste Disp Cost <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> Dirty Filters NR S 3 Bags 39.4 lbs $55.16 <br /> Dirty Blue Shop Towels NR S 1 Bag 9.4 lbs $13.16 <br /> Bando Dusting NR S 4 1 gal 20.4 lbs $28.56 <br /> Reducer, Acetone and Paint 3 L 1 1 gal 1 gal $3.50 <br /> Reducer and Paint 3 L 1 1.5 gal 1.5 gal $5.25 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $125.63 <br /> Clean Earth Check-In Attendants Initials: %n Date: <br />