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06/26/2014 TUE 14: 40 FAX �QQ1/001 <br /> am11855 W1 IIT14-ROCK ROAD Date of Evcnl: <br /> RANCHO CORDOVA,CA 95742 Timc: s 3 o Q.PI-7 <br /> (916)351-09HO lnfnnncd: <br /> ENMONMENTAL SERVICES Tune,¢Participaied: <br /> -- � •- GRUUY <br /> Wcxcin Rcg4on <br /> CONDITIONAL LY EXFMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CEICrIF ICA1'ION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that the following inforination is correct,and I have read and understand the requirements tilT participation in the Philip <br /> Trausport:ation and Remediaticm inc.Conditionally FXempt Small Quantity Generator Waste Acceptance Prop-am. I filtther certify that i <br /> nm a Conditionally Exempt Small Quantity Generator as defined by Federal and Calibrnia State:regulations,and this quantity of waste <br /> does not exceed thu spucif ed limits liar the type o1'waste being disposed. If this waste is tater found to exceed small quantity limit~ or <br /> contain matmials not accepted auderthis program,I agree to complete a ha7nrdtiu.c waste manifest and comply with otherstate regnlations <br /> as appropriate. i�22 <br /> COMPANY NAME: 00rK 1a; COMI'ANx Itl;t': D V qq <br /> n <br /> COMPANY ADDRE88: IAS+ E11A TD#: (off 0 U 0GI eq�l - j <br /> CITY,STATE,ZIP: L�C; CSE{ �j� � SIGNATURE: <br /> COM PANYI't1.O1V1,: TITLE: JJ7 DATE: <br /> TO BE COMPLETED BY PLIIL,LP TRANSPORTATION& Ri;MEWATION HECK-IN ATTENDANT <br /> GNNRRAL WASTE DESCRIPTION HAZARD All STATE, St H OF CONTAINER WASTB WTQ.H) DISI! COST <br /> CREMICAT.CONSTITUENT Ph. CTC. CLASS • WASTE CODE L CONT TYPEISM AMOUNT MHTH <br /> k ke soles cAa 5ZS0 <br /> TO- <br /> Qaf tS'tvc � 3 �. <br /> METHOD OF PAYMENT: CASH O CHECK ❑ CHECK NO. ��?R 'TOTAL PAID$ <br /> PHTT.TP TRANS&REMED CHECK-IN ATTENDANTS INITIALS DATE -25 Ll <br /> [rsGw7 lcav UU/ll CHFCIC-TN RECEIPT <br />