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05/03/2013 FRI 1107 FAX IQJ001/001 <br /> RECEIVEL <br /> 11855 WHITE I;OCK ROAD JUN 2 2 2015 Dry al,R�,t: <br /> RANCHO C ORDOVA.CA 95742 Tim*: _, C <br /> (916)351-M)KO Inforalcd: <br /> Rr4v11l0NMItN'CA1.%1MVl1=5 ENVIRONMENTAL.ibm Participated: <br /> GROUP iJCAi rE��GP�gT1�CAT <br /> Wasmn jt%,k. <br /> CONDITION LLY EXEMPT SMALL QUAN FIT GENERATOR WASTE <br /> C1iEC 4N RECEIPT AND CERTIFICATTON STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information in currcct,and I bavc rc:ul and understand the requirements for participation it%the Philip <br /> Tranwportation and Remediation Inc.Conditionally Exempt Small Quantity Generator Waste AzoViance Program_ 1 further certify that 1 <br /> am a Conditionally Exempt Small Quantity Gencratar as datined by Fcdcral and Calitnrnia State regulationg,slid this quantity of waste <br /> docs not c:xcce:d the specified limits dor the type of waste being disposed. If this waste is later found to excoed small quantity limits or <br /> contain materials 4ot accepted under this program,l agm to complcte a hazardow waste manifest anti comply with other state regulations <br /> as appropriate. <br /> CUMPANY NAnw: C S C COMPANY'It � <br /> COMPANY ADDRESS: C&I <br /> SIGNATURE: 7 Gid. <br /> C.'OMPANV PRO I.: j TITLE: DATE: <br /> TO BE COMPLETED BY P ILIP TRANSPORTATION&RRM MIATION CHECK-IN ATTENDANT <br /> GLNLKAL WAS77i OR9(:RFPrON HAZARD AH STAn S! a OP CO wAsiv wr(La) t)1SY. ME- <br /> >riAdICALCCIN671't' ult 1-Ph, t:. CLASS WASTE CODE L COM TY <br /> IMMM AMOUNT bETII <br /> n <br /> METHOD OF PAYMENT: CAS /� CHFICK 0 CIMCK NO. TOTAL PAID S <br /> PHILIP TRANS dt:REW0 CTfF.(7t-TN 't" 24"ANTS IkUrfA.LS sem- DATE Z1 <br /> PsCan7 "V0111 CHECK-IN RECEIPT <br />