Laserfiche WebLink
11855 WHITE ROCK ROAD <br />RANCHO CORDOVA, CA 95742 <br />(916)351-0980 <br />Date of Event: L/ -26 G13 <br />Time: li✓f%n <br />Informed: <br />Timet Partirinated: <br />..� � GROUP ...,.......- <br />Wicacem 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 />4 <br />In a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, and this quantity of waste <br />loes not exceed tho specified limits for the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br />ontain materials not accepted under this program, I agree to complete a hazardous waste manifest and comply with other state regulations <br />s appropriate. j�/J � �% 1 <br />�V <br />�, �1� � FLS_ <br />J l �' ao"e r r bf l� 1N� W� COMPANY REP: <br />:OMPANY NAME: / I �_Iff <br />;OMPANYADDRESS: C Lt.).CCic; (�t EPAID#: (/ LCf 12 �' i` rL <br />_ J <br />QTY, STATE, ZIP: SIGNATURE :1 ft.L-L -i2 <br />:OMPANY PHONE: (�i) L} 1V TITLE: r. DATE: <br />TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN .ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />CHEMICALCONSTiTOENT. Ph.. ETC.) <br />HAZARD AH STATE S/ I # OF CONTAHNTIl. <br />CLASS WASTE CODE L TYPPISIZIF <br />WASTE WItt B) DISP. I COST <br />_ AMOIIN I' METH <br />,Y/t. sU4'e4f <br />!CONT <br />)! vc Css l, TT C-•- <br />FEi <br />Dna of Evem: OGt 3�, 7er j <br />Time p0� n- <br />Ioformed: <br />"r—, ramaratea: <br />C'tt\1tI Ilst I I \ 1\EMPTSMALLQUANTITYGENERATORWASTE <br />C III I I. I N RECEIPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />I ceniC)-that the following tn(otmotion is corrcc4 and 1 hn'2 read and understand dre reyuircmmv for perticipatioo in rhe Philip <br />I farther certify dot I <br />n<porrnnen ud Ranediarinn Inc. Cnndinonally Exempt SmaE Quantity Generator Wasm Acceptance Program. <br />m a C. ditionally 6xempl Srnall Qondty Genoramr ss defined by Federal and Caltfamla Smre regulations, and this gvandry of waste <br />k+es nor exceed the specified limits fur the type of waste being d'upo,.d. If this waste is lacer found m exceed amnll quantity Limits or <br />utn material. rwt accepte0 undtt this pmgrarts, 1 agree to complete a hazardous waste manifest and Comply with oNer sate regulations <br />a appropnarc. <br />NAbtF: /��/I�1C1L �1� <br />T.-- <br />E. ZIP: 7i7k C:fl <br />L1e",e15 COMPANYREP: YytDnflC_ <br />EPA IDH: (ir..rt2gbf <br />1c^� SIGNATI'RL•': <br />t y(/ TITLE: - .:r DATE <br />CASH pi, CHECK ❑ CHECK N0. <br />rG!/Gro t t� <br />TOTAL, rAus_ <br />IN <br />�J <br />