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r,E311855 WHITE ROCK ROAD nr,te of Event: Z- Y-i 2 QJ� <br /> 1UNCITO CORDOVA,CA 95742 Time: rJ, 00�G� <br /> (91,)351.0980 Informed: <br /> ENVIRONMENTAL SERVICES Timm Participated: <br /> GROUP <br /> Wawvn R*ou <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO HE COMPLETED BY GENERATOR: <br /> I certify tllat the following inforniation is correct,and I have read and underRtand the requircmcrrt9 for participation in the Philip <br /> Tritngporindon and Remediation Inc.Conditionally Exempt Slnall Qunntity Genemtor Waste Acceptance Program. I fibber certify that 1 <br /> am a Conditionally Exempt Small Quantity Generator as defincd'by Federal and California State regulations,and this quantity of waste <br /> does not exceed t11e specified limits for the type of waste being disposed. If this waste is later found to execcd small quantity limits or <br /> contain materials nut accepted under this program,l agree to complete a hazardous waste inanifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAME: V u 4-� (,,���nn�{ r1��i COMPANY REP: ICI f 6k V1 p� <br /> COMPANY ADDRESS: U� C ,f►I�I��I��IXl? f/ �L� JOIA ID#: (,A/__, <br /> CITY,STATE,ZIP: SIGNATURE: <br /> COMPANY PHONE: q0q) (� iL' 0305 TITl.f: /,J�/r%t2 I)ATI.: - ;�- l�� <br /> TO BE COMPLETE BY kHILIPTRANSkORTATION &UMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD All STATE SJ N OF CONTAINER WA$TA WT(1.0) DISP. COST <br /> HRMICALCONSTITIIP.N7 Ph. FT(:.) CLASS WASTF. Cr7DR L CONT TYPEISIZE AMOUNT METH <br /> METHOD 010PAYMENT: CASii CHECK ❑ CHECK NO. TOTAL,PAID S <br /> s <br /> PHILIP TRANS&RL'MED CTIEC:K-IN AITENDANTS INITIALS L)ATF. <br /> Psc.20 ARV N11 CI IE CK-IN RECEIPT <br />