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�� Date of Event: ms L CL S' / <br /> i-: � � 11855 WHITE ROCK ROAD <br /> �� RANCHO CORDOVA,CA 95742 Time: l 5 i!0�r ; <br /> (916)351-0980 Informed: <br /> ENVIRONMENTAL SERVICES . Times Participated: <br /> GROUP <br /> Wes,em R4on <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 /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, and this quantity 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 o,her state regulations <br /> as appropriate. <br /> COMPANY NAME: (TJ 1-1-16 COMPANY REP: L`- _ <br /> r —� <br /> COMPANY ADDRESS EPA IA . L S U` �'tl I <br /> CITY,STATE,ZIP: c'p' s;=J;�it,f �'�1 'U�� SIGNATURE: � <br /> : T DAT Z51COMPANY PHONE: i TITLE <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #1 OF I CONTAINER WASTE4 WT(LB) DISP. COST <br /> (CHEMICAL CONSTITUENT.Ph..ETC.) CLASS WASTE CODE L CONT 1 TYPE/SIZE I AMOUNT METH <br /> L,-v^tJ <br /> E <br /> J 1 � <br /> METHOD OF PAYMENT: CAS% CHECK ❑ CHECK NO. TOTAL PAID <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS DATE <br /> n <br /> 08111 �^j,y1 �-�f l� CHECK-IN RECEIPT <br /> PSC-207 REV 08 <br />