Laserfiche WebLink
395 WEST CHANNEL ROAD <br /> f Event: <br /> BENICIA,CA 94510 Time: <br /> iiim(877)748-3040 Aatco InJ'onncd: <br /> Et�tVZ*QN A,1ZNTA1.SF,RVICL7s <br /> CROUP ---- . 3 imcs Participated: <br /> ��iblrltl I♦GYian <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERI,TOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that the following information is con•ect,and-I4nd�the requirements for participation in the Philip <br /> Transportation and Remediation Inc. t Small Quantity Generator Waste Acceptance Program, I further certify that 1 <br /> am a t Small Quantity Generator as defined by Federal and California State regulations, and this quantity of Waste- <br /> does <br /> astedoes 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, , ,J n <br /> COMPANY NAME: •_/v� �v! l� COMPANY REP: <br /> COMPANY ADDRESS: 5/ EPA ID7t: 000;7-1 �j <br /> CITY,STATE,ZIP: �^ �-0� SIGNATURE: <br /> CON,IPAN Y PHONE: ( ) �' �(/(/ TI7'LL: le S DATE: 7 3 ,,Zd11 <br /> a <br /> ;4M°1 Ila - 0903 <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENTERAL WASTE DESCRIPTION HAZARD AR STATE S/ 0 OF CONTAINER WASTE WT(LB) DISP. COST <br /> CI•IEMICAL CONSTITUENT Ph. ETC. CLASS WASTE CODE L CONT TYPE/SIZE A_MOUNr METH <br /> �aGeS�i .tori •o <br /> METHOD O> PAY IVII✓NT: CASAU CHECK CHECK NO. l •I'OT'A PAID <br /> L' <br /> PHILIP TRANS &RFMED CI•IECK-IN ATTENDANTS INITIALS DATE <br /> CI•IECK-IN RECEIPT <br /> PSG207 0.0\�IUIIU <br />