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03/05/2010 WED 9: 18 FAX RECEIVED <br /> 10001/002 <br /> 11855 WI- IlTL ROCK.Roari MAR 24 2014 D ��f 8 <br /> ate vem7 , <br /> RANC110 CORDOVA,CA 95742 Time: CLN•I <br /> (916)351-0980 ENVIRONMENTAL HEALTH iafonncd: <br /> ENVMONMENTAL SERMCUs PERMIT/SERVICES Tunes ranicipatcd: <br /> _.. _ GnuuP <br /> wewfaftlm <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CI ECK-IN RLCICIPT AND CERTIFICATION STATEMENT <br /> 110 BT COMPLETED BY GENERATOR: <br /> 1.ecrtiry that the following information is correct,and T have read and understaral the requirements for participation in the Philip <br /> Trauspottntion and Remediation Inc. Conditionally Lsxempt Small Quantity Generator Waste Acceptance ProgrntD. I further certi I'y that I <br /> aro a Conditionally Exempt Small Quantity Generator as defined by Federal and California State re&rulation.s, and this quantity of W,Sic <br /> aloes not exceed the specified limits 1'or the type of waste being disposed. if this waste ix later found to exceed small quantity limits of <br /> contain materials not accepted under this program,I agree to complete a hazardous waste manifest and comply with other state regtdationx <br /> as appropriate. <br /> COMPANYNAME: F}tJ FO �,`�QA-l2. JCOMPANYREP: <br /> COMPANY ADDRESS- , `��]I�I�� �(M�SO�Sf EPA IDM: LOOO22l`fSa <br /> CITY,STATE,ZIP: .��fbC-K1 041 L/C q CIV 0 o SIGNATURE: �2 � <br /> COMPANY PUONE: d6r-7) TG �� %13z TITLE: fe) (f,/) fes- DATE: <br /> V <br /> TO BE COMPLETED BY PHILIP T14ANSPORTATION & REMEDINfIGN CHECK-IN ATTENDANT <br /> 0GNLRALWASTRDWSCRIN'1'ION IIAZA14D All STATE SI p01+ CON'I'MM'11L WASTE WT(I.R) oNF. coS'r <br /> CIIENUCALCONSTI'1'IIHN'r Ph. Inc. CLASS WASTE CODE, L CONI' IYPWSIZE AMOUNT MI>1'H <br /> -I-- SS 3o a( 2015 In, <br /> �i►1 7rtivn / SS a/ 33-- <br /> aL-ev, he <br /> ZS <br /> FNt.pt�.l <br /> AX-- <br /> Ar— <br /> ME'11I0I)OF PAVMF,NT: CASH O CHICK C:IMCK NO. TOTAL PAID S_ <br /> P1IILIP'1'14ANS&RF.MF.D Cl4F.CK-IN ATTENDANTS INITIALS �� �' - DATE '� ) <br /> s<r]m nmoml 0TFC:K-TKRF-CF1PT <br />