Laserfiche WebLink
395 W ST CHANNEL ROAD <br />BENIC A, CA 94510 <br />(877) <br />ENVIRONMENTAL SERVICES <br />-- GROUP - <br />Wen= Region <br />Date of Event: 0) 'V_ <br />Time: ,Ir" ()n t i i rt <br />Informed: <br />Times Participated: <br />CONDITIgNALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CH CK -IN RECEIPT AND CERTIFICATION STATEMENT <br />I certify that Elie followin, <br />Transportation and Remediation Ii <br />am a Conditionally Exempt Small <br />does not exceed the specified limi <br />contain materials not accepted and <br />as appropriate. <br />COMPANY NAME: <br />COMPANYADDRESS: <br />CITY, STATE, ZIP: <br />COMPANY PHONE: <br />TO BE COMPLETED BY GENERATOR: <br />information is correct, and I have read and understand the requirements for participation in the Philip <br />Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify thatI <br />quantity Generator as defined by Federal and California State regulations, and this quantity of waste <br />for the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br />this program, I agree to complete a hazardous waste manifest and comply with other state regulations <br />t,.11'� ICiUJ COMPANY REP: jii� 1 Y a'nAr1I <br />n <br />Y A—,I -A In UApy�1t�� EPA ID#: <br />CA 015 ZLrj � J SIGNATUR <br />7 ,�J S TITLE: `%ZDATE: <br />FSC -2107 REV 70<10 <br />�)vC))V_iG <br />L <br />r 6SP <br />M -I) <br />CHECK -Ili RECEIPT <br />0 <br />TO BE COMPLETED BY <br />HILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />(CHEMICAL CONSTITUENT. Ph. ETC. <br />HAZARD <br />CLASS <br />ALHSTATE <br />WAS"t'E <br />CODE <br />S! <br />L <br />OF <br />CONT <br />COIvTALNER <br />TYPE/SIZE <br />WASTE <br />AMOUNT <br />WT(LB) <br />DISP COST <br />METH <br />on,t <br />�i <br />aI(,j <br />0o W s <br />1 112 11b <br />toc) <br />c <br />) 1 <br />METHOD OF PAYMENT: CAS <br />PHILIP TRANS & REMED CHECK -I <br />D CHECK D CHECK NO. TOTAL PAID S ° �� <br />ATTENDANTS INITIALS <br />FSC -2107 REV 70<10 <br />�)vC))V_iG <br />L <br />r 6SP <br />M -I) <br />CHECK -Ili RECEIPT <br />0 <br />