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08/02/2012 THU 18:03 FAX <br />®001/001 <br />11855 WHITE ROCK ROAD Date of Event: R—U f 6, zo I z <br />RANCHO CORDOVA, CA 95742 11mc: ; 00 C M <br />(916) 351-0980 Informed' <br />ENVIRONMENTAL SERVICES Times Participated: <br />GROUP <br />wookm Aeon <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR 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 ccrtify that I <br />am a Conditionally Exempt Small Quantity Generator as deftned'by Federal and Califomia 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: %finla-'200+5 COMPANYREPt <br />COMPANY ADDRESS: EPA IDpt <br />CITY, STATE, ZIP: !� n r CA SIGNATURE: e 44 a'/1, <br />COMPANY PHONE! �C�) r, `7 " L _ TITLE: SCS"L����_ 111Lt1,u�;�'rDAT)E: <br />TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CRECK-IN ATTENDANT <br />WORN I JIM lklffmi 1:901 <br />..: <br />r� <br />�r��■��■�■rrwr■ <br />r���■r■�■■�rrr■r■ <br />METHOD OF PAYMENT- CASH ❑ CHECK ❑ CHECK NO. TOTAL PAID $ C <br />PHILIP TRANS & REMED C]iFCK-]N ATTF,NDANTS INITIALS <br />� l,` - DATE <br />PSC -207 RGv OBIT I <br />- CHECK-IN RECEIPT <br />� Q� <br />Credit Card Ending In l <br />