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eEnil= <br /> ♦ s'' 11855 WHITE ROCK ROADGir y � <br /> Date of Event_ <br /> s RANCHO(ORDOVA,CA 95742 Time: <br /> (916)351-0980 Informed: <br /> ENVIRONMENTAL SERVICES Times Participated: <br /> GROUP <br /> Wesrcn Region <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO RE COMPLETED BY GENERATOR: <br /> I certify that the following ' ormation is correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Inc. onditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> am a Conditionally Exempt Small Q ntity Generator as defined by Federal and California State regulations, and this quantity of waste <br /> does not exceed the specified limits r the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br /> contain materials not accepted under is program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> r � � <br /> COMPANY NAME: -� L� � COMPANY REP: - ���l �J7G✓� Z � Z <br /> COMPANYADDRESS: I , r� 1 EPA ID#: 1� z j C _SSIr <br /> CITY STATE,ZIP: �� ' '7 �_ Gid L� SIGNATURE: <br /> COMPANY PHONE: ( ) �' �/7 TITLE: r�r1 .�� DATE: <br /> TO BE COMPLE'T'ED BY P IP'T'RANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> OEHE&AL WASTE DESCRIMON OAZARD AH STATE S/ #OF -CONTAINER WASTE WT(LB) DISP. COST <br /> f05PNr1CAL rONSTTTtIFNT Ph. ETC CLASS WASTE CODE L CONT TYPFISIZE AMOUNT METH <br /> 01 <br /> / (J ,J <br /> 4,5 IV14 <br /> METHOD OF PAYMENT: CAS ❑ CHECK 'O(CHECK NO. �, TOTAL PAID S <br /> PHILIP TRANS&REMED CHECK-IN TTENDANTS INITIALS DATE 16_' .� /_33 <br /> PSC-207 REV 0811, CHECK-IN RECEIPT <br />