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11.355 l�rhOLte Ro& Gid. <br /> CleanEafth Rancho Cordova, CA 957742 )ate: 2/212023 <br /> (gang -"511-0980 <br /> C0HB[f L0KALLV EXELAPT SM ALL QL A 9,MY GENERATOR WAPASTE CHEC E44N' Ab'\'10 CER N IFICATION <br /> be cornpcete 9 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 1 agree to complete a hazardous waste manifest and comply with other <br /> state regulations as appropriate. gmoezi983luz@gmaii.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: KAC'u `i Goyyte? <br /> Phone Number: 209=810-8756 Title: OU­�ndate. (52 -0 I Z� <br /> TO BE COMPLETED BY STERICYCLE CHECK-IN ATTENDANT <br /> General Waste bescription(Chemical Haz. Alif State #of Container Total waste Total Waste Disp <br /> Constituent;Ph,WTC.) Class waste Code Cont. Type/Size (qal/fC) (pounds) Meth Cost <br /> Dried Paint -- NR L 1 5 gal 32.6 lbs $17.50 <br /> Antifreeze and Oil NR L 1 1 gal $3.50 <br /> Dried Paint NR L 2 1 gal 17.2 lbs $7.00 <br /> Dried Paint NR L 1 1.25 gal 10lbs $4.38 <br /> Paint 6:1 L 1 1 gal 4 Ibs $3:50 <br /> Old Bando Waste NR S 2 Egal 11.6 lbs $16.24 <br /> Old House Paint 6.1 L 1 42.,6 lbs $17.50 <br /> Mix of Acetone,Reducer and Paint 3 L 1 6lbs $3.50 <br /> - — - — — — _ <br /> Paint Mix Waste 6.7 L 1 1 gal 9.2 lbs $3.50 <br /> Dusty Filters NR �-5-- 7 Bags - 31.7 lbs $44.38 <br /> Processing Fee $20,00 <br /> Method of Pymnt'. Cash ------ Check# I ny, Total Paid: $141.00 <br /> Clean Earth Check-In Attendants Initials:: Date: <br />