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.NOV. 1. 20120 3:08PM11AX F otal System No. 2428 P. 4/4.loot <br /> 11655 WHITE ROCK ROAD DatcofEvcN: �V' 3� ' (y�2 <br /> RANCHO CORDOVA,CA 95742 7Sma pOa'tT1 <br /> (916)351.0980 lnronned: <br /> !N%IftnVMN 1f�:09AVEC9E Times Puticipated! <br /> Q60TIP <br /> We.wnllerba . <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTI✓ <br /> CHFCK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO HE COMPLETED BY GENERATOR: <br /> I codify that the following information is correct,and I have read And understand the requirements for participation In the Philip <br /> Traosportation and Rornediation Inc.Conditionally Dxempt Small Quantity Generator Waste Aeoeptanco Program. I further certify that) <br /> attt a Coaditiorlally Exempt Small Quantity Qcneralor.as defined by Federal and California State regulations,and this quantity of waste <br /> docs not exceed rhe specltled limits for tiro type of wast+being disposed, If this waste is later found to exceed small quantity limits or <br /> contain mntaflals not accepted under this pragram,I agree to complete a hazardous waste manifest And comply with other state regulatiorrs <br /> as appropriate. <br /> COMPANYNAME: '�-(J�� �' - COMPANYREP: <br /> COMPANYADDRESS:I (AkEPA IDN; (A LO 'Z,Q <br /> CITY,STATE,7.IP: SIGNATURM aaQ <br /> COMPANYPHONE; (zb�) 'M-Mo TITLE: y -J' DATF.: 1 )_?l —12- <br /> T5 HE COMPLETED BY PHILIP TRANSPORTATION &REMEDIATION CIIECK-IN ATTENDANT <br /> ORNRRALWASTEDESCRIPTW nAZARD Ali STATE st NOP CONTAINER A87E WT(LE) DISP. COST <br /> CHP.MICAl TIAIENT Ph. HTC CLASS WASTECONT AMOUNT <br /> (.IJP 60 <br /> G 1 Meet HSL IM6 <br /> 11 � Z•S Ut.Bs ,�,do <br /> u " -e Z.1 I <br /> METHOD OF PAYMENT: CASH ❑ CHECK Q CHECKNO. TOTAL PAIDSyt.-._ _ ��,I0, / <br /> PHILIP TRANS&R$MED CHECH-IN ATTENDANTS INITIALS _, DATE 10- <br /> POC-161 <br /> 0°-ass:el WWII C•C4 CHECK-IN RFCFIPT <br /> 1-7h-r ! .'A / ' <br />