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2013 PRI 17106 FAX x0021002 <br /> - G , <br /> 11855 WTIrTR ROCK ROAD nate pf Rvent: <br /> RANCHO CORDOVA,CA 95792 TSrna -� <br /> (916)351.0980 r Izrforrxiaa: <br /> ENV13tONM33NTAL 68R'VICES � Ttnle6 F:ll't1SJ.p3tad: <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STA.TRMXNT <br /> TO BE COMPLETED BY GENERATOR: <br /> I cortify that Lhe following infonrlation is cbmc:t,and 1 have read and understand the requirements for participation in the Philip <br /> "1Yansporta6on and Rernediatiou Inc.Conditionally Exempt Small Quantity Generator WastC Acceptance Program, I further certify that I <br /> ca <br /> am it Conditionally Exempt Small Quantity Generator ae deftned by Federal and Califomia Stat:regulations,and this quantity of wasta <br /> deer not exceed the specified limits for the type of waatc being disposed. If this wa.sw is later found Lo cxiXed atnall quandly limils or <br /> contain materials not acccptr;d utrder this program,I agree to mrnplete a hazardous waste manifest and Garnply With other aisle rOgulutioos <br /> as appropriew— �� <br /> COMPANY NA]4IEe �Uli �( C�,.I�(�a COMPANY REP: S C O <br /> COMPANY ADDRESS: 1L[40 Lj,_14WgVj- ZPAID#; CAQO d7 <br /> CITY,STATE,ZIP r LQ 1 i.SA Clg ' SIGNATURF: <br /> COMPANY PHONE,, (5go� TITLE. 1`"I "`"�1'r" SATE I <br /> 34 <br /> 2419 001- 1A01- - <br /> TO BE COMPLETED BY PRIX.II'TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> GUNURAL WASTE USCRIPTION 3-RAZAAD A1i STATE F1 4 OF C ONTA1NIaR WASTF- WT(LH) DISP, COST <br /> CEDM ICALCONSTMJENT PA ETC. CLASS WASTE CODE t, nbNT_ TYPPJSILl3 AMCLINTqP MBTH <br /> LCt-k-� •�,a F <br /> M 1nQ�ee, <br /> [[I <br /> I. <br /> 1 <br /> METHOD OF PAYENT^ CASH Q CHECK C3 CI-1ECK NO. <br /> IMd fila 'DOTAL PAID S 0-1 <br /> - <br /> PHILIP TRA,NS&RF.MF,D CIiFC-K-IN AT7PWDANl'S TNI'I"IALS DATE rt <br /> ' P$G207 ARVWfl7 <br /> CHECK-IN RECEIPT <br />