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1181,Vlihite Roek Rd. <br /> CleanEaORancho Cordova, CA 9,74.2 (date: 2/1/2023 <br /> ��16� 3,10380 <br /> airn 9:15 AM <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE CHECK-IN AND CERTIFICAT10k <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> o 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 /> Smadi 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. gmoez1983iuz0gmail.com <br /> Company !Name: Ramirez Body Shop Company Rep: Luz Gomez <br /> Company Address: 1200 N Filbert Street EPA ILS# CAL000453194 <br /> Stockton CA 95205 Signature: -_ _t- h�tcty;it ���rrn��7 <br /> Phone (Number: 209-810-8756 Title: 0 vq­ Date. o 7 - 0 1 L� <br /> 'TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste Description(Chemical Haz. Ali State S)L #of Container Total Waste Total Waste Disp Meth COSI <br /> Constituent,Ph,WTC.) Class Waste Code Cont. Type/size (pal/ft) (pounds) <br /> Dried Paint IVR L 1 5 gal 32.6 lbs $17.50 <br /> Antifreeze and Oil INR L 1 1 1 gal I $3.50 <br /> Dried Paint INR L 2 1 gal 17.2 lbs $7.00 <br /> Dried Paint INR L 1 1.25 gal 10 lbs $4.38 <br /> Paint 6.1 L 1 1 gal 4 lbs $3.50 <br /> 01d Bando Waste INR S 2 1 gal 11.6 lbs $16.24 <br /> Old House Paint 6.1 L 1 5 gal 42.6 lbs $17.50 <br /> Mix of Acetone,Reducer and Paint 3 L 1 1 gal 6 lbs $3'50 <br /> Paint Mix Waste 6.1 L 1 1 gal 9.2 lbs $3.50 <br /> Dusty Filters INR S 7 Bags 31.7 lbs $44.38 <br /> Processing Fee i $20.00 <br /> Nlethod of Pymnt: Cash Check# Iny, Total Paid: $141.00 <br /> Clean Earth Check-In Attendants Initials: ` � late: j <br />