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DBtC 9f Event: / <br /> 11855 WHITE ROCK ROAD Time: s �R/► <br /> RANCHO CORDOVA,CA 95742 Informed: <br /> (916)351-0980 Times Participated: <br /> ENVIRONMENTAL SERVICES <br /> GROUP <br /> W"rcm Rrglw <br /> CONDITIONALLY EXEMPT SNUiLL QUANTITY GENERATOR WAST <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPL ED BY GENERrequiATOR: <br /> I certify that the following information is correct and iavuantity Geread and neratoriand the <br /> Waste Ac epttancc Program. I ements for participation <br /> certify thatI <br /> Transportation and Remedration Inc. Conditionally ExemptQ this quantity of <br /> am a Conditionally te <br /> Exempt Small Quantity GeneratWeas ste beeitn disposed.r If thal a waste is laterfoundtoyexceed small quantity 1 mrtssor <br /> does not exceed the specified limits for the type of <br /> contain materials not aste manifest and comply with other state regulations <br /> accepted under this program,I agree to complete a hazardous w <br /> as appropriate. <br /> S Y r\ eaL4�� COMPANY REP.d/�(M;`� <br /> COMPANY NAME: O EPA ID#: <br /> COMPANY ADDRESS: <br /> SIGNATURE: <br /> CITY,STATE,ZIP: TITLE: DATE: <br /> �`�,�.=��...a._c�- <br /> COMPANY PHONE: <br /> TO BE COMPLETED BY PHILIP TRAI`tSPOR ATION & REMEDIATION WASTE W (AB DI�ANO T <br /> A}i TATE S/ O METH <br /> GENERAL WASTE DESCRIPTION HAZARD WASTE ODE L COM 'IYPEISIZE AMOUNT <br /> CHEMICALCONSTITUENT Ph. ETC CLASS I � cd ( ZWA f <br /> DO r D n Coil/ ,N`L I al I <br /> LdW a4 <br /> A <br /> S <br /> Od <br /> AY s a� aI <br /> 6 r l IZ tD.l oj� 7 ,76 <br /> sots 2eyA ►4�G <br /> EN I G <br /> DEP <br /> OD OF PAYMENT: CASH ❑ CHECK CHECK NO. <br /> 1 TOTAL PAID <br /> METH � <br /> DATE (f /(, <br /> PHILIP TRANS& REMED CHECK IN ATTENDANTS (NI ALS CHECK-IN RECEIPT <br /> I'SC-207 REV08111 <br />