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EGEIVEL, n/ 7 <br /> Detc of Eveat>t' '{� `V�Cr <br /> 11855 wHnE ROL ROAD I��V 2 o Mb Time: <br /> RANCHO ColiDOvA,CA 95242 V fe InEortaed <br /> (916)351-09811 Ttmn PaNripeted' <br /> V, ,, c&LENVIRONMENTAL <br /> ENERATOR Weio„Ik6ie� t.{F.hl'7'1-A f�COeOTR6FN? <br /> CONDITIONALLY RECEIPT SMALL RTIFFIICAATION STATEMENT WASTE <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following iatormatioo is correct,and 1 have read and ncrato rledWa the requirements for m- I f v thea in the <br /> 1 <br /> Transportation and Remediation Inc.Conditionally Exempt Small Quantity Geterator Waste Acceptance Prograr <br /> am a Conditionally Exempt Small Quamf a Generator waste <br /> d�ng dbpo��If hs Cwastet st later found o exceed email quanons,and thig tity limitssor <br /> does not exceed the specified limits for the type <br /> complete a hazardous waste manifest and comply with other sate regulations <br /> contain materlals not accepted under this prolcem,t agree to <br /> as appropriate. <br /> COMPANY REP: I <br /> COMPANY NAME: � EPA IDIr: <br /> COMPANY ADDRESS: Z 5 G� sICNATURR: <br /> crrxSTATE,z�: q3 ;ZPa_ TITLE: 54o(Lflom ffil rE: IL <br /> COMPANYPHONE: 0% <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION&REMEDIATION C�HECIC- ATTENDANT <br /> Ax STATE sr 0O CoxfM+E <br /> CO .WASTED E6CNPt2 C HAZARDWASTE C L Co P24 AM <br /> 43 lI 4y7v <br /> 4, 204 <br /> 0 r FS ASO <br /> METHOD OF PAYMENT: CASH ❑ CHECK ❑ CHECK NO. TOTAL PAID S_ <br /> PHILIP TRANS&REMED CHECK-TN ATTENDANTS INITIALS DATE <br /> CHECK-IN RECETPT <br /> ne.rov eaveeIu L Af ftJJ <br /> � m�ncun Erx <br /> 3rouo <br /> <5 Credit Card Ending In <br />