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EB11355WH)TEROCK MAD Date of Eve �1 / <br /> RANCHO CORDOVA,CA 95742 Time:o <br /> (916)351-0980 Informed: <br /> ENVIROMAUN-1hL SRVICES Times Participated: - <br /> GROUP <br /> CONDITIONALLY EXEMPT SMALL QUANTITYGENERATOR 1 V E D <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMEN l Y LLLL <br /> TO BE COMPLETED BY GENERATOR: APR 0 3 2013 <br /> AQ I certify that the following information is correct,and I have read and understand the requirements for pie TY <br /> ]p <br /> Transportation and.P,emediation Inc.Conditionally Exempt Small.Quantity Generator Waste Acceptance Program, � I4f <br /> am a Conditionally Exempt Small Quantity Generator as defined V Federal acid California State regulations,and tbis 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 otber state regulations <br /> as appropriate. ff^_ <br /> COMPANYNAME: �mw z AWE)-. BaCOMPANYREP: f\yyLjE W IYe� <br /> COMPANYADDRESS:-[0`L-.moi_. �. - NF1 1 7iV -1Ar!!- EPA IDN: <br /> CITY,STATE,ZIP:l�' �(7C:Y. Qf�3 -CA 01,32_©S SIGNATURE: <br /> COMPANY PHONE:`- OO[) ZLg4S _ aJW1z TITLE: DATE:. � � <br /> TO BE COMPLETED BY PITILIP TRANSPORTATION&REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD Ali STATE S/ 4O- CONTAINER WASTE I WT(LB) -DISP. COST <br /> CHEMICALCONSMUENT Ph..ETC. CLASS WASTE CODE L CONT TYPEAME AMOUNT MHTH <br /> L T <br /> JL4 <br /> METHOD OF PAYMENT: CASH CHECK ❑ CHECK NO. TOTAL PAID S <br /> ?HILIP TRANS&REMED CHECK-IN A. TENDANTS INITIALS <br /> •sC-zn: Ravat t �� CHECK-TN RECEIPT <br />