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1.��/2013 BRI 13: 00 FAx • ®002/002 <br /> 11955 WRITE ROCK ROAD Daft of Event: <br /> RANCHO CORDOVA,CA 95742 Timc: nOC> /Lt <br /> (916)151-0990 Infomtcd; <br /> E NVI RONMEN'1'AL SERVICES <br /> -- - -- GROUP Times Participated: <br /> tYfvLLWr4�w, . <br /> CONDITIONALLY FXF,MPT SMALL QUANTITY GENERAPOR WAS'W <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERACOR; <br /> I certity that the following information is correct,and 1 have read and understand the requiretnente for participation in the Philip <br /> '1'nntsportaliou and Remediation Inc.Conditionally Exempt Small Quantity 0encrator Waste Acecptanco Program. I fvrfher certify that I <br /> am a Conditionally Exempt small Quantity Venerator 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 fotuld to exceed small quantity limits Or <br /> contain materials not accepted undra this program,I agree to complete a hazardous waste manifest and comply with other slate regulations <br /> as appropriate. <br /> -C ��/( / ,` <br /> OMPANY NAME: Y" l� 04 WQLt,I T' Cts, COMPANY REP; <br /> COMPANY ADDRESS: Z Z Ll(IS/I11 L4Jd t' EPA 1D#: <br /> CITY,STATE,ZIP: !, JDGti Yl, <br /> COMPANY PHONE: QG�f) — Q 0( TITLE: DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-TN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HA7.ARD AN srAtY S/ KOt� CONTAINER WASTE WT(L31) r)hp (Y1.5'r <br /> CHEM[CAT.0 N9TITURNT Ph RTC. CLASS WA"I'tt L'OUL' L COW T1ZWIZE AMOUNT METH <br /> 7F- (.GUY�SC�Z <br /> METH0DOFPAVN1ENT- CASH ❑ C:HIWK ❑ CHUCK NO. TOTAL PAIV$ 4 Y <br /> PHILIP TRANS&RF,MED CHECK-IN ATTENDANTS INITIALS ! Q, DATE <br /> PSU207 xhv twit <br /> CHECK-1N RECEIPT <br />