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EZ311855 WHITE ROCK ROAD Date of Event: 11z '4 I l y <br /> RANCHO CORDO VA,CA 95742 Time: ,o cutis <br /> (916)351-0980 Informed: <br /> ENVIRONMENTAL SERVICES Times Participated: <br /> GROUP <br /> We tcm Pcgio <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 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. 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 found 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 appropriate. r n n <br /> COMPANY NAME- SO <br /> � -.)V I�I ���+�. M V C J COMPANY REP: <br /> N <br /> COMPANY ADDRESS: s / H'/ /f"W a-V EPA ID#: CR LU LAG 2 J <br /> CITY,STATE,ZIP: C tC:C.�, G f') C% t 2�' f SIGNATURE: <br /> COMPANY PHONE: ( ) GZ�Z- j TITLE: DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DISP. COST <br /> CIIEMICAL CONSTITUENT Ph- ETC. CLASS WASTE CODE L CONT TYPE/SIZE AMOUNT METH <br /> t l 2 4 <br /> 6 L»5�1 11 C. -kX 20 <br /> - <br /> METHOD OF PAYMENT: CASH ❑ CHECK ❑ CHECK NO. TOTAL PAID$ <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS DATE <br /> PSC-207 REV 08111 CHECK-IN RECEIPT <br />