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Date of Event: I <br /> 11855 WHITE ROCK ROAD Time: / df�h? <br /> RANCHO CORDOVA,CA 95742 Informed: <br /> GM(916)351-0980 Times Participated: <br /> VI <br /> ENRONMENTAL SERVICES <br /> GROUP <br /> Wesrrm Regf°° <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WAST <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,Sm ll Quantity Generator e read and tand the Wsste Ac eprements tancc Program. I participation <br /> fiuther certify thati <br /> Transportation and Remediation Inc.Conditionally p this quantity of <br /> am a Conditionally Exempt Small Quantity Generator <br /> of waste being n ds disposed.Federal <br /> lf the waasteris latetfou d to xrce d small quantity limitsote <br /> r <br /> does not exceed the specified limits for type <br /> -ontain materials not accepted under this program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> S Y n p,,L+j M4:COMPANY REP:�/a M(�M;`� <br /> COMPANY NAME: D EPA #: CrTL � li, <br /> COMPANY ADDRESS: <br /> SIGNATURE: <br /> CITY,STATE,ZIP: DATE: <br /> COMPANY PHONE: ) Q� TITLE: <br /> TO BE COMPLETED BY PHILIP TRANSPOR ATION & REMEDIATION CER �fIECK-INASTE (ATTENDANT toT <br /> GENERAL WASTE DESCRIPTION HAZARD AH TATE S/ MHTH <br /> CHEMICAL CONSTITUENT Ph. ETC. CLASS WASTE ODE L CONT TYPE! AMOUN C <br /> er I al <br /> Lam � 1 <br /> low <br /> 01) <br /> US IZ lolo 16 V1 <br /> Z�,Rd �,3 <br /> Z .4 6R l,�b <br /> Sots Iq,� <br /> Int <br /> rot�1 � <br /> /a U f <br /> '.Irq <br /> $ <br /> CASH ❑ CHECK CHECK NO.J TOTAL PAID <br /> METHOD OF PAYMENT: <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS <br /> DATE �f <br /> CHECK-IN RECEIPT <br /> MC-207 mvoviI <br />