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am11855 WHITE ROCK ROAD Date of Event: <br /> RANCHO CORDOVA,CA 95742 Time: alf Im <br /> (916)351-0980 Informed: <br /> ENVI RONNIENTAL SERVICPq Times Participated: <br /> ------ GROUP ---- <br /> �t'ex,em Re�rn <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and 1 have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Inc.Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, and this quantity of waste <br /> does not exceed the specified limits for the type of waste being disposed. If this waste is later fount) to exceed small quantity limits or <br /> contain materials not accepted under this program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropri:ic. f p }p (� <br /> COMPANYNAME: CACI (,�. COMPANY REP: <br /> e ( C t-���1\Um M� I�e <br /> COMPANYADUItESS: r 111-1�P6 (title EPA IDN: 6/1�(]LI(l'1' <br /> CITY,STATE,ZIP: .�,- 004 1 �,A efff 5i M'%'L SIGNATURE: �- <br /> COMPANY PHONE: (76q) W6 '711 TITLE: DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & RFMEDIATION CHECK-IN ATTENDANT' <br /> GENERAL WASTE DESCRIPTION IIAZARD Ali STATE S1 HOP CONTAINER WASTE T(LB) DISE COST <br /> w <br /> i OWMICAL CONSTITUENT Ph..E C.) CLASS WASTE CODE. L E. A <br /> CONI' TYPESIZE. MET I'1 <br /> lua�s� 9 ,y S� KU <br /> — JAN 19 2 18 <br /> NWItNT-AL HEALT <br /> METHOD OF PAYMENT: CASH U CHECK ❑ CHECK NO. TOTAL PAID$ <br /> ?,r2 <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS DAI'E <br /> 10 ' �s'n CHECK-IN RECEIPT <br />