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05/28/2014 WED 8: 12 FAX I�401/001 <br /> 11855 W1dlTh RUCK ROAD Date o1'Fvciw kcs/z <br /> RANCHO C'ORDOVA,CA 95742 Timc; <br /> (916)351-09HR Informed: <br /> I1NVIRONMi;NTALSERVICES Timcs Participated: <br /> CROUP <br /> W[c0em ntgirut <br /> CONDITIONALLY EXEMPT SMALL QTJANTTTV CENI+;IIXI'Olt WASTE <br /> CHECK-IN RU,CJUPT AND CERTIFICATION STATEVfEN1' <br /> TO DE COMPLE'T'ED BY GENERATOR: <br /> I certity that the fbl(owing iuformarioll is correel,incl I have:read and undor51-lnd the r�quireilteuts for participation in the Philip <br /> Tralasportation ntld ltemodiation Inc.Conditionally Exempt Small Quzultity Genernlor Waste Aecepianec Program. I further certify that i <br /> am a Conditionally Exempt Smith Qultlltity Generator ns defined by Fedcral and California State regaitions, and 11lis qualttity of waste <br /> doer not exceed the specified limits lbr the type of waste beiug disposed. If this Wnste is luta found to exceed~mail quantity limits or <br /> =)Iftin materials not acccl)tcd tinder this program,I agree to complete a hazurdow wa..Mc manifest and comply wifli other state regulations <br /> as appropriate. (( r <br /> COMPANYNAMA:: VuS� Ca 1 COM VA NY REP: Chris (0 1�Q�, <br /> COMPANYAD))RESS: h� Cj,'59q0 EPA i))#: 17`j 00 JSy 2 <br /> CITY,STATE,ZIP: %c C4 SIGNATO RE: <br /> COMPANY PHONE: (?eqb, TITLE: ✓p !)NNE: a /� <br /> 2'9q J 70 ^ 2_ 5' <br /> TO BE COMPLETED BY PHILIP TRANSPORTATXON & RLEMEDIATION CHECK-IN ATTENDANT <br /> GUNL•RALWAErll 13MCKIA'ION HAZARD All STATE S/ 9 01; t:OUrAINN.R WA$TE WT(L13) DISI'. COST <br /> (CIMWCALCONS't'I1•uLN'IPh.,U)'(:.) CI.AR`1 WASTE CODE L CONT TYPUNIZIi AMUtrNT ME ; <br /> l ccaSc �� / (91 I go <br /> p <br /> i k�Cr+uI Octlis t;(,cc� 3ex& Ft!w <br /> lme�u l N I e 9765 z� <br /> AJC q Zo <br /> IUJ4 '14 <br /> MET UOD UN PAYMENT: CASH ❑ CHFCKlid ICIIECK NU� 0 TOTAT.PAID$ <br /> Yl11Lll''1'RANS b'c REMED CHECK-!N ATTENDANTS INITIALS - T)ATR f <br /> PSr..207 kFvW11 C:fiF.C;K-IN11ECEIPI" <br />