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0 <br /> ca11855 WHITE ROCK ROAD DateofEvent <br /> RANCHO CORDOVA,CA 95942 Time: <br /> (916)351-0980 Informed: <br /> ,NVIRONMENTAL SERVICES Times Participated: <br /> GROUP <br /> ' Wcsrem Rrgvo <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPTAND CERTIFICATION STATEMENT <br /> v <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation.in the Philip, <br /> Transportation and Remediation Inc.Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I 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 /> containmaterials not accepted under this program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAME: ✓G'�iJ ��{/'(LC/�� �:r_f4i �C=� j COMPANY REP: {-o. I� <br /> COMPANY ADDRESS: �� rlt/r );Il L-;�1 �/ !•J/%<:�e,(_ 1"fir'/ EPAID#: 6;9(000, <br /> CITY,STATE,SIP: _� !' r- ' <br /> �; j%'" SIGNATURE: <br /> GlA- <br /> COMPANYPHONE: 6/L e TITLE: ., DATE: c•_ <br /> .$:;Nfn,., f•IiLeU I.sr:u,ro <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S! #OFCONTAINER WASTE WT(LE) DISP. COST <br /> (CffFAIICAL CONSTITUENT Ph,RICA CLASS WASTE CODE L CONT TYPEISIZE AMOUNT METH <br /> :l E.. <br /> SE , 1 0 2014 <br /> EN <br /> METHOD OF PAYMENT: CASH ❑ CHECK 0 CHECK NO. (-4 TOTAL PAID$ <br /> PHILIP TRANS&REMPD CHECK-IN ATTENDANTS INITIALS DATE _ G� <br /> ----- —203CHECK-IN RECEIPT <br /> `! <br /> tEDIT CARD ENDING IN <br />