Laserfiche WebLink
11855 W3.41TE ROCK ROAn Date of Evcnt: L <br /> 9 . Timc: � ✓�'� <br /> RJANCF10 COPDOVA.CA 95742 DEC 21 3 2011 inf�Timc: <br /> (916)351-0980 <br /> FmM <br /> Timcs Participated: <br /> ne— <br /> GROUP <br /> v�emm Aeon <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR.WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that the.following information is correct,and I have read and understand the regttirements for participation in the Philip <br /> Transportation and Remediation Inc- Conditionally Exempt Small Quantity Generator Waste Acceptance Program. 1 further certify that I <br /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, and this quantity of waste <br /> does not exceed the specified limits for the type of waste being disposed. if this waste is later found to exceed small quantity limits or <br /> contain materials not accepted under this program,I agree to complete a hazardous waste manifest and comply with other state regulation.- <br /> as <br /> egulationsas appropriate. <br /> COMPANY NAME: W COMPANY REP: -ecA. <br /> COMPANY ADDRESS: t EPA IDtI: <br /> CITY,STATE,ZIP: �Qc)l—L CA !�l SzgQ _ SIGNATURE: <br /> COMPANY PHONE: (` _ TITLE: b✓1Z / DATE: I <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION &REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DlSY. COST <br /> CHEMICALCONSTrTUENT Pli. ETC. CLASS WASTE CODE L CONT TYPF,/S17E AMOUNT METH <br /> S 1 <br /> METHOD OF PAYMENT: CASH D CHECK 0 CHECK NO. TOTAL PAID S �© <br /> PHU?TRANS& RE•MED('HECK-IN ATTENDANTS INIVA1-S - ;�— DA )- - <br /> 'C ITECK-IN RECEIPT <br /> PSC-207 REVOP11 <br />