Laserfiche WebLink
11855 WHITE ROCK ROAD Date of Event: Z(4 I 1Y <br /> RANCHO CORDO VA,CA 95742 Time: <br /> (916)351-0980 Informed: <br /> ENVIRONMENTAL SERVICES Times Participated: <br /> GROUP <br /> Western Region <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. / <br /> COMPANY NAME: 'So '`. Oa I,(I I'1 (_U�ln {V�v CJ COMPANY REP: <br /> COMPANY ADDRESS: s GJ l Q f 0.y EPA ID#: C LOOCZ S� <br /> CITY,STATE,ZIP: -/-C)CGS G'j') .C/ 2 C', SIGNATURE: <br /> COMPANY PHONE: 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) DISE. COST <br /> CHEMICAL CONSTITUENT PiL ETC. CLASS WASTE CODE L CONT TYPE/SIZE AMOUNT METH <br /> hcejoite- S Li 4-U q,6 <br /> METHOD OF PAYMENT: CASH ❑ CHECK ❑ CHECK NO. TOTAL PAID$ 2 <br /> PHILIP TRANS&REMED CI-IECK-IN ATTENDANTS INITIALS DATE <br /> PSC-207 REV 08/11 CHECK-IN RECEIPT <br />