Laserfiche WebLink
11855 WHITE ROCK ROAD RECEIVEDDateorEvent: Jean. 28 2015 <br /> RANCHO CORDOVA,CA 95742 Time: Q fl� M <br /> (916)351-0980 JAN 2 8 2 G i:) Informed: <br /> ENVTRONMENTAL SERVICES rimes Participated: <br /> GROUP <br /> ENVIRONMENTAL HEALTH <br /> CONDITIONALLY EXEMPT SMALL(q@ ( IG@VERATOR 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 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•notaccepted under this program,L agree to complete a.hazardoss waste manifest and comply.with other state regaiations <br /> as appropriate. <br /> COMPANY NAME: Palacios Ornamental Iron Works COMPANYREP: Ana Pequero _ - <br /> COMPANYADDRESS: 527 S. Wilson Way EPAID##: <br /> CITY,STATE,ZIP: StoCkton, CA 95205 SIGNATURE: - <br /> COMPANY PHONE: (209) 483-1463 TITLE: iA, I t ; 5 DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION& REMEDIAT16 CHECK-IN ATTENDANT <br /> GENinuT WA5TE 173SCrupTION HAZARD AH STATE St H OF CONTAINER NVAtiTC WT(LB) P. COST <br /> (CHLMICAL CONSI7TUE T,-11h..FTC.) CLASS WASM CODA L. CONT TYPRISrZ6 AMOUM' MB'H <br /> Water/Degreaser Mix 2 5 cal_ 10 gal-_ 91 i�saa <br /> „t T. t A.1 .5 _ �O:VV <br /> Steel 1 ubjnq Dust <br /> 90- <br /> ProcessingFee � � <br /> METHOD OF PAYMENT: CASH ❑ CHECK CHECK NO. �I TOTAL PAID$ 138.955 <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS _ _ DATE <br /> PSC-207 REV 08/11 CHECK-IN RECEIPT <br />