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11855 WHITE ROCS{ROAD ( 1 <br /> I� Date Of Evtyit: v / <br /> RANCHO COPDOVA,CA 95742 Time: � ' �� f7-7 <br /> (9 16)351-0980 Infnrm t; <br /> RNVIRONM$NTAL%RVtCX5 <br /> GROUP Time P"Gipared: <br /> �tttcm tiry�ioa <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RIECE;!PT AND CERTIFICATION,'STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Inc. Conditionally Exempt Small Quantity Generator Waste Acceptance Program. 1 further certify that I <br /> am a Conditionally Exempt SmaJ1 Quantity Generator as defined by Federal and California State rzgulations,and this quantity of waste <br /> docs not exceed the specified limits for the type of waste being disposed. Tf this waste is later found to exceed small quantity limits or <br /> contain materials not accepted under this program,I agree to complete a hazardous waste maniftst and comply with other state regulations <br /> as appropriate. <br /> tt <br /> COMPANY NAME: � Lr I C�`�iP1� CON111ANY REP: <br /> COMPANY ADDRESS: � i. �� Q�J`cz r� U`�4 EPA UM: <br /> CITY,STATE,ZIP: t � t�i✓1,p L �� SIGNATURE: <br /> COMPANY PHONE: (Z� ���-(�� �� TITLE: / j � )DATE: /A// <br /> nC?I _ <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-1N Al-rENDA NT <br /> GENERAL WASTE DESCr71PTIDN IIAZA" AH STATE Si r1OF CONTAINER WASTE WT(Lb) DISP. COST <br /> CHEMICAL 00KSTTT1JENt'Pb. ETC. CLASS WA$TP CODE L CONT TYPC'r'SIZE A1.9OUN'T MFTH <br /> METHOD OF PAYMENT: CASH 0 CIHECK ❑ CHECK NO. TCtTAL PAID 6_0 <br /> PHILIP TRANS R.EMED CHECK-IN ATTENDANTS INITLALSDATE /* ? <br /> _.�,:�._ <br /> sac-zoo REV ce,o, "^ Crcdit Card Ending In ' CHI CK 1 e1 RECEIPT <br />