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11855 WhRe Rack Rd. <br /> L^;'l e a n E a h , Rancho Cordova, CA 957142 Date. 3/312023 <br /> ggmv�352.-0980 <br /> Time: 8:00 AM <br /> CONDITIONALLY EXEMPT SMALL QUAN79TV GENERATOR "WASTE CHECK-IN AND CERTIFICATION <br /> RECEIPT AND CERTIFICATION STATEMENT <br /> To be C®mp�eted 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. gmoezl983luz@gmail.com <br /> Company Name: Ramirez Body Shop Company Rep: Luz Gomez <br /> Company Address: 1200 N Fi1beft Street EPA ID# CAL000453194 <br /> Stockton, CA 95205 Signature: tiNO .`3 ,. <br /> (� <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 #of Container Total Waste Total Waste Disp <br /> Constituent,Ph,WTC.) Class Waste Code SQL Cont. Type/Size (gal/ft) (pounds) Meth Cost <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 FeeE- 1 I E$20.00 <br /> Method of Pymnt: Cash Check# +W Total Paid: $86.50 <br /> Clean Earth Check-in Attendants Initials: jy <br /> ®ate <br /> - --.SIT CAR ,nonjo 1 <br /> - a <br />