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Date Of Event: <br /> Time' i)�'�001 <br /> 11855 WHITE ROCK ROAD A 95742 <br /> RANCHO CORDO Informed: <br /> (916)351-0980 Times Partic�pa�d. <br /> EN'VI RONr+rENAL SERVICES <br /> GROUP <br /> OR Wm�Regw <br /> AST <br /> CONDITIONALLY EXEMPT <br /> SN ULLL CERTIFICATION QUANTITY NERAVIENT <br /> CHECK-IN RECEIPT <br /> TO BE COMPLETED BY GENERATOR: <br /> Waste Acceptance Program. I further certify that I <br /> n information is correct and have read and understand the requirements for participation in the Philip <br /> 1 certify that the following <br /> Generator <br /> Federal and California State regulations, and this quantity of waste <br /> "Transportation and Remediation Inc. Conditionally Exempt Sm II Quantity <br /> am a Conditionally Exempt Small Quantity Generator as defin d by with other state regulations <br /> does not exceed the sp <br /> deified limits for the type of waste bein disposed. If this waste is later found o exceed small quantity limits or <br /> I agree to co plete a hazardous waste manifest and comp y <br /> contain materials not accepted under this program. g <br /> as appropriate. Q r; <br /> �f COn4PANY REP: <br /> COMPANY NAME: 0 e EPA 11)4: <br /> COMPANY ADDRESS: ry SIGNATURE: <br /> CITY,STATE,ZIP: r �U DATE: 1-01L 1�/ <br /> am) TITLE: r''l_-'`}�,. <br /> COMPANY PHONE: <br /> TO BEC <br /> OMPLETED BY PHILIP TRANSPOR ATION & RE CONTAINER <br /> �AS <br /> e K-W-17(1-11) <br /> DISDANOT T <br /> NTBTH <br /> HAZARD TATE S/ k Of TYPFJS[ZE AMOUNT / <br /> CHEMCALCONSTrTUP_NTtPTIOP), ETC CLASS WASTE ODE L CONT 1 u( <br /> p0 e Q P.r1�- I a� <br /> La n I <br /> Dart � al 30 <br /> ( 6 r I <br /> VSA , Ion <br /> sots 20cP� 14 t: <br /> M � <br /> roreSsi tG <br /> L t� <br /> CHECK NO. y ' TOTAL PAID$ <br /> XETHOD OF PAYMENT: CASH D CHECK r� �L <br /> DATE 7 <br /> PHILIP TRANS&REM.ED CHECK-TN ATTENDANTS [NI ALS CHECK-IN RECEIPT <br /> t'$C:-10 REV 08/II <br />