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r �r r• r a - 'QVVc/ VVc <br /> 911555 WH17 F ROCK ROAD Dnte of Evsnt. <br /> RANCHO CORDOVA,CA 95142 Time: <br /> (916)351-0980 taformed: <br /> ENVIRONMENTAL SL'Rt7CSLS Times Participated: <br /> GROUP <br /> Wra,om Aaglm - <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WWAS'I'E <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED 13Y GENERATORi <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 Acccptanoc Program. I further certify that'l <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 materiala not accepted under this program,l agree to complete a hazardous waste manifast and comply with other state regulations <br /> as appropriate. <br /> COMPANYNAME: () ('.�Q0.1 I °t.(S Q,(rP.S �nrlC e S COMPANY REP: ''•�j('(\rl 1 rl <br /> COMPANYADDRESS: 'Z(O I E. C f,&L'P71 0—r W t/ EPA IDN: (_ OOZ TZ 7 <br /> CITY,STATE,ZIP: SJOCKy"Ol C4 95265 SIGNATURE: <br /> COMPANY PHONE: (2o9) - /�Y& O VS-a DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERALWASTE DESCRIPTION .HAZARD AA STATE S1 aOF CONTAINER WASTE WI.") DISP. COST <br /> CHEMICAL CONSTITUENT Ph.,ETC. CLASS WASTE CODE L CONT TYPE/SIZE AMOUNT METt1 <br /> /4 KAlia 2da er�e'S l L) Jc 5 Tv <br /> ro�P,S5in t'e. Za.00 <br /> I <br /> 0 <br /> I I <br /> I I f <br /> I <br /> METHOD OF PAYMENT: CASH ❑ CIiECK ❑ CHECK NO, TOTAL PAID $ ?f2176) <br /> PHILIP TRANS &REMM CHL+C ATTENDANTS INITIALS DATE <br /> _ t <br /> PSC207RP.vawn .3t/Y,•C CHECK-IN RECEIPT <br /> 3 E t e v e 0 _ r Credit Card Ending In <br />