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..� 11855 WHIT CK ROAD !� <br /> RANCHO COkDOvA,CA 95742 Date of lTime — 2 <br /> (916)351-0980 Time: t ;a0 <br /> 0MROMMENT.ILLSEItV10ES Informed: <br /> GROUP Times Participated: <br /> �.a1em loon <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 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 farther certify that I <br /> am a Conditionally Exempt small Quantity Generator as defined by Federal an <br /> -a California State regulations, and this q►tantity 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: C COMPANY REP: U.t C+ <br /> COMPANYADIDRESS: `?��C3 LT� � � o EPAIDII: <br /> CITY,STATE,2'1?- (D31( � (D31 a 7 SIGNATURE: <br /> COMPANY PHONE: (201:k l 717 TITLE: �x/Cj/ e2 DATE: <br /> rCHE <br /> BE COMPLETED B PH LIP TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> NERAL WgS7E DESCRiPT10N HAZARD AH STATE S! N OF CONTATt�tER WASTE WT(LB) DISP. COST <br /> M1CALCONsrtTt�errr Pt,, ETC. CLASS WASTE CODE L CONT TYPESIZE Alypr Marx <br /> 4 <br /> IETHOD OF PAYMENT: CASH 0 CHECK CHECK NO, ' <br /> —.117 OTAL PAID S <br /> HILIP TRANS & REMED CHECK-IN ATTENDANTS INITIALS DA Z S% <br /> 0.207 REQ 01V i i <br /> CHECK-IN RECEIPT <br />