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11855 White Rock Rd. <br /> CleanEafth Rancho Cordova, CA 95742 Date: 10 J(y/2022 <br /> (916)351-0980 <br /> Time: 8:15 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 laterfound <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. gmoe2l9831uz@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 /> C. <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. AH State #of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code S/L Cont. Type/Sae (gal/ft) (pounds) Meth Cost <br /> Dirty Filters NR S 4 Bags 43.5 lbs $60.90 <br /> Dirty Blue Towels NR S 1 Bag 8 lbs $11.20 <br /> Bando Waste NR S 2 1 gal 10.6 lbs $14.84 <br /> Mix-Reducer,Acetone and Paint Waste 3 L 3 1 gal 3 gal $10.50 <br /> --FM 7T 2u23 <br /> 1)1`1) 1:I N F.N.I. <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash X Check# Inv Total Paid: <br /> $117.44 <br /> Clean Earth Check-In Attendants Initials: di. <br /> � � <br /> Date: <br />