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11855 WHITE ROCK ROAD Date of Evoot <br /> RANCHO COROVA,CA 95742 Time! t/y ' �,(�GAtn--� <br /> D <br /> (916)w-0980 Informed: <br /> aNVIppNMKNTAL 55RN[SS Times Participated: <br /> GROUP <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 1 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 other state regulations <br /> as appropriate. cc <br /> COMPANY NAME: 4 1 S �� ICn COMPANY REP: <br /> COMPANYADDRESS: EPA TDH: r O <br /> CITY,STATE,JJP: _ "45i0CK+C n CSA Q3 SIGNATURE: _ <br /> COMPANYPHONE: '20} 41 13 S� TITLE: �7�t.. -� r DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIMON RA2ARD AH STATE S/ a OF CONTAINER WASTE WT(L13) DISP. COST <br /> CNEWC.AL CONSTITUENT Pb.ECC. CLASS WASTE CODE L CONT TYPEISIM AMOUNT METH <br /> u40bes <br /> o <br /> METHOD OF PAYMENT: CASH ❑ CHECK ❑ CHECK NO.!` C-ITOTALPAIDS <br /> PHILIP TRANS &REMED CHECK-IN ATTENI]ANTS INITIALS - <br /> "t^i <br /> vcc.w7 aev nx:�i D�S� f'FiF('x_TTT ACf`ervr <br /> e <br /> Credit Card Ending In <br />