Laserfiche WebLink
I <br /> JAN 2 7 2012 <br /> 11855 WHITE ROCK ROAD Date of Event: <br /> RANCHO CORDOVA,CA 95742 SAN JOACUTA COUN1 Time: t <br /> (916)351-0980 ENVIRONMENTAL informed: <br /> EbMgoNMWrM MnM°P'S HEALTH DEPARTMF. 0 Times Participated: <br /> csrcour <br /> waw Rcgm I <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-LN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following i0formation 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 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: 4 �! C f COMPANY RE P: <br /> I <br /> COMPANY ADDRESS: 1010 EPA ID#: o �Z I <br /> CITY,STATE,ZIP: OCk��� �;� ,��� S SIGNATURE: <br /> COMPANY PHONE: ) `tom _ Q J� <br /> C� ���l S TITLE: „t DATE: r ?� <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE Si #OF CONTAINER WASTE WT(LB) DISK COST <br /> CHEMICALCONSTTTUENT Ph.,ETC. CLASS WASTE CODE L CONT TYPFJSIZE AMOUNT METI t <br /> C� l c, ja <br /> a2cens rl <br /> METHOD OF PAYMENT: CASH([•.;,\CHECK ❑ CHECK NO. (TOTAL?AIDS IW, 5Q <br /> 6 i, E <br /> PHILIP TRANS&REA4ED CHECK-TN ATTENDANTS INITIALS ��,�„ D <br /> PSC-207 REV 011 CHECK-IN RECEIPT <br />