Laserfiche WebLink
11855 WHITE ROCK'rbAD <br />RANCHO CORDOVA, CA 95742 <br />(916)351-0980 <br />iNVIRONMENTAL SERVICES <br />GROUP <br />-W Date of Event: <br />Time: $: Df i rc r,I <br />Informed: <br />Times Participated: <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENER�TOR 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 tte lip <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. _ <br />COMPANY NAME: ��-�(� (t,1(.l \ 1 Cl'1 f wQ,� `, I COMPANY REP: " I (j1 1'� <br />COMPANY ADDRESS: -7-`�1�J EPA ID#: C.•�� 'L 2 <br />CITY, STATE, ZIP: 1��)( �L, j�� f CAA (4_j A2 SIGNATURE: <br />COMPANY PHONE: 4(p - 2 ZZ TITLE: DATZ <br />TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />CHEMICAL CONSTITUENT Ph.. ETC.) <br />HAZARD <br />"CLASS <br />AH <br />- WASTE-"- <br />STATE <br />-CODE <br />St <br />L <br /># OF <br />" C-0NT <br />CONTAINER <br />TYPESIZE <br />WASTE <br />AMOUNT <br />WT(LE) <br />DISP. <br />METH- <br />COST <br />-- <br />YE 16 <br />ltr� C� I <br />1 <br />all <br />L aA <br />7 <br />Q <br />v <br />0 <br />VIETHOD OF PAYMENT: CASH ❑ CHECK ❑ CHECK NO. �l D NGl NC- <br />'i-IILIP TRANS & REMLD CHECK-INATTENDANTS INITIAL <br />TOTAL PAID $ <br />DATE <br />2b. C�o <br />sC-307 REVOB/❑ CHECK-IN RECEIPT <br />