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0 <br /> 11855 WHITE ROCK ROAD Date of Event: 0(4, 23 20(4( <br /> RANCHO CORDOVA,CA 95742 Time: 4Z' <br /> (916)351.0980 Informed: <br /> GNVYRONMENTALSERVTCES Times Participated: <br /> GROUP <br /> we rc P4gm <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <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 /> contain materials 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: c�A( 1.� CC COMPANY REP: <br /> COMPANYADDRESS: -/�'" ` ,. �1 Q r l�C. EPA ID#: OAA r <br /> CITY,STATE,ZIP: jai CA a 52�A I SIGNATURE: <br /> ( ) sAT : QCOMPANY PHONE: 42TITLE: DE2 � <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION&REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ a OF CONTAINER WASTE WT(LE) DISP. COST <br /> EN <br /> CHEMICALCONSTTTUENI'Ph. ETC. "CLASS WASTE.- _CODE L CONT TYPEJSIZE AMOUNT &M-M <br /> "zt �2 <br /> To 51, �" ctS2 <br /> C FL <br /> bni �b 5 39, o <br /> 2C5 3 4 i <br /> VI �_ N L HE LTH <br /> DEPART ENT <br /> 2 <br /> METHOD OF PAYMENT. CASH ❑ CHECK ❑ CHECK P TOTAL P S 12)2.2 <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS r DATE <br /> CHECK-IN RECEIPT <br /> psQwl ftEV OB/It <br />