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09/07/2012 TUE 19: 03 FAX 2002/002 <br /> 11655 VMITR ROCK ROAD Date of Event: <br /> RANCHO CORDOVA,CA 95742 Time: <br /> (916)351-0980 Informed: <br /> ENVIRONMENTAL SERVICES 37mca Participated: <br /> GROUP <br /> Wca�em Rc�on <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. 1 further certify that I <br /> am a Conditionally Exempt Small Quantity Generator as defined by Pederal 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 prgrarn,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> • COMPANY NAME: L m n �a,` COMPANY REP: 'J <br /> COMPANY ADDRESS: (�'?�� G. ,p(r}�. EPA ID#: _r A-C Z7_-0 1112 q <br /> CITY,STATE,ZIP: �,`� (YA 2 QS SIGNATURE: 1-1-SIGNATURE: ���J C7Du_Ra <br /> COMPANY PRONE: TITLE: \dDATE: V g aoix <br /> 20q 5-11(o IT l <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GPNPRAL WASTP DESCRIPTION I1A2ARD AH STATE S/ it OF CONTAIN1311 WASTE WT(LB) DISP. COST <br /> CHEMICAL CONSTITUENT,Ph. ETC• CLASS WASTE CODE L CONT TYPPJSIZE AMOUNT METH <br /> QI'V1 i UI U 27 <br /> GI ycp F—theAr PM 5 lion <br /> 5v tnvl-6r � <br /> Etnv sifter Fvutr- 2 '/2 <br /> Drs ar-lon H <br /> —Mvskov Sal vc„f 3 I/2 <br /> 117- <br /> C's -q(00 4 y <br /> METHOD OF PAYMENT: CASH D CHECK J2 CHECK NO, TOTAL PAID $ � r <br /> P141LIP TRANS& REMED CIIECK_m ATTFNDANTS INITIALS t DATF <br /> NSC-20 RBB oath CHECK-IN RECHIPT <br />