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11855 WHITE ROCK ROAD Date of Evcnt: blZ <br /> RANCHO)CORDOVA,CA 95742 Timo; <br /> (916)351-0980 Informed: <br /> ENMRONMENTALSBRVICEB Times Participated: <br /> GROUP <br /> wftuTn n�glan . <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that tete following information is correct,and I have read and understand the requiren-wnts for participation in the Philip <br /> Transportation and Remediation Inc, Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> rain a Conditionally Exempt Small Quantity Generator as defined by Fedoml and California State regulation, and this quantity of waste <br /> does not exceed the specified limits for the type of waste being disposed. If this wa9tc is later found to exceed shalt quantity limits or <br /> contain matcrialg 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: r 1 '961 I, 0t V,S COMPANY REP: Q r) <br /> COMPANY ADDRESS: A) 11rovo, EPAIDli: C Pr 9 f 70 <br /> CITY,STATE,ZIP: 4ocA*m SIGNATURE: <br /> COMPANY PHONE: TITLE: ;si/',t/ DATE: <br /> Z"( " <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK- 1V ATTENDANT <br /> GENERAL WASTE r)ESCRIPTION HAZARD AH STATE Sf 0 OF CONTAINER WASE WT(LB) DISP, COST <br /> CIIEMICALCONSTITUEI%'r,Ph.,ETC, CLASS WASTE CODE L CONT TYPIU-MEQ AMOUNT METI3 <br /> METHOD OF PAYMEN . CASH CHECK ❑ CHECK NO. TOTAL PAID S <br /> 22_0i Z <br /> PHILIP TRANS&REMED CHECK.-IN ATTENDANTS INIT DA's Z�° <br /> rsc.-2a� r�vos?t CHECK-INRECUPT <br />