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11855 White Rock Rd. <br /> CleanEafth Rancho Cordova, CA 95742 Date: 3/1/2023 <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. gmoez1983iuz@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 COSI <br /> Constituent,Ph,\ATC.) Class Waste Code Cont. Type/Size (gal/ft) (pounds) Meth <br /> Old Dry Mixed House Paint NR L 1 5 gal 48.6 lbs $17.50 <br /> Old Mixed House Paint 6.1 L 2 5 gal 100 lbs $35.00 <br /> House Paint 6.1 L 1 1 gal 2.1 lbs $3.50 <br /> Dirty Shop Towels NR S CNTR 5 lbs $7.00 <br /> Mix of Actone,Reducer and Paint 3 L 1 1 gal 4.2 lbs $3.50 <br /> Processing Fee $20.00 <br /> Method of Pymnt: Cash Check# Inv Total Paid: $86.50 <br /> Clean Earth Check-In Attendants Initials: Date: <br />