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1) 855 WRITE ROCK ROAD Date of <br />RANCjit) CORDOVA, CA 95742- Time: eo <br />(916)351-0980 Informed: <br />ENMONMENTALVIM <br />SER <br />GROUP times Participated: <br />Watem 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. Coritfitionally Exempt Small Quantity Generator Waste Acceptance program. I further certify that I <br />am a Conditionally Exempt Small Quantity OenCTato'r as defined VFederal and California State regulations, and tbisuantity 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 other state regulations <br />as appropriate. -SAO <br />Lab <br />COMPANY NAME: & Ll Y__C%r),S QQr+Cj4 COMPANY RZP: —0 <br />COMPANY ADDRESS: (RO I 'Q'rxrr.,,j EPA 1D#: <br />CITY, STATE, ZIP: L00 <br />aj.bo veri rA. SIGNATURE: <br />COMPANY PHONE: <br />TITLE, C1 <br />TO BE COMPLETED ]BY PHILIP TRANSPORTATION & REMEDIATION CHECK -IN <br />'ATTENDANT <br />_�_rNr <br />XA1' WAsjb utscu—iJUN HAZARD IAH STATE <br />S <br />i �� <br />I��WTt�DISp. �COSTLLC* CAL CONSTITUENT, Ph., ETC. CLASS WASTE rrF)pIIJn � <br />I <br />KETHOD OF PAYMENT. CASH 13 CJJECX 0 CHECK NO. <br />141UP TRANS & REMI=T) CHECK -TN ATTENDANTS INITIALS <br />TOTAL PAIL) $ <br />_ < <br />rs N-- <br />W-207 h1vOh; 11 C z'A CHF-C)K-IN RECEIPT <br />—wh 40MM <br />MW 4momb <br />