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r <br /> ,10/0,2/'2013 WED 9t 21 FAX ®001/001 <br /> 11955 WHITF ROCK IWAO Datr.of Event: QCfi2 �i3 <br /> RANCHO CORDOVA,CA 95742 Time: // l <br /> (qui)751-n4Rt1 litfonncd: <br /> ENVIAONMEN7ALSEEVICE9 Timex participated: <br /> . . .._.. . GROUP .. ..._ <br /> CV..tcn,A"W, <br /> CONDYFIONALI Y F,XT.MPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERACOR: <br /> I certify that the following information is correct, and 1 have rad and understand the requirements for pfirticipation in the Philip <br /> Transportation and Remediation luc. Conditioually Exempt Small Qu:urtity Generator Waste Accclitance Program. I further certify that 1 <br /> am a Conditionally Exempt Small Quantity C;cncretor ax defined by Fulcral Rud California Slate regulations, and this quantity of waste <br /> does not exceed the specified Limits for the type of waste beiuE disposed, If this waste is later found to exceed small quantity limits or <br /> contain materials not accepted under this program,I agues to cumplcle a ha[tlydOLIS waste manifest and comply with Other state rcgulatinns <br /> as appropriRte. <br /> COMPANYNAW: �� ' ' + t I COMPANYREP/n:1 <br /> COMPANVADORK,SS: S rvl 6rgL1h EPA IDS: <br /> (T'1'V, S'I'ATTS,7,[i': S t [3� � 6'f" SIGNATURE: <br /> COMPANY PHONE: Qpm) �t CCS —0 6`4 <br /> Z <br /> TO BE CoMPLE'11,1)BY PTil],IP TRANSPORTATION Sx RENTEDTATION CHECK-IN ATTENDANT <br /> C'G CALCONST UIIS=,TIONC IfAZARD wh. IE COTE S/ CONT rT✓f FAJS17.1 AMOUWANNT w�'tl..u) MUT11 C:ON'1' <br /> 'n oll <br /> ;1V <br /> a co <br /> Focea6f � <br /> FEE EE <br /> METHOD OF PAYMENT: CASH ❑ CHL;CK ❑ CHLCK NO. f0T•AL FALL) y J 33,00 <br /> pH1LIP TRANS& REMED CHECK-1N ATTENDANTS INITIALS DATE f <br /> `'✓ CIMCK-IN RECEIPT <br /> 1'aliLU% lt2 0 <br /> Credit Card Ending In <br />