Laserfiche WebLink
12-27-'13 11;10 FROM-Cost-U-Less Ins. 209-464-6465 T-332 P0002/0002 F-304 <br /> RECEIVED <br /> 11855 WH1TE ROCK ROAD + *F Date of Event: ��i ~{ <br /> RANCHO CORDOVA,CA 95742 Z 7 20 k� � J l � J � <br /> (916}351-0980 Informed: <br /> ENVIROMMM4TAL ENVIRONMNTA6Brt;�;paced: <br /> ftRee HEALTH DEPARTMENT <br /> wpm <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 certify that I <br /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and California Mate 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 tinder this program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> n <br /> jj <br /> COMPANY NAME: -ari rl(i 1� ilk <br /> COMPANY ( I t (�' �_4 COMPANY REP: <br /> COMPANYADDRls53• _ ��`v . i['t� 1���' ?�c`t.t.f EPA 10i �!%t,;'`r' A-' .' <br /> IGNATUR :CITY STATE ZIP: - <br /> /y— "� <br /> r <br /> COMPANY PHONE: (�'.r f) - � `. TITLE: Qt,'J,rC;alV ATE: I <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION&REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S1 *OP CONTAINER WASTE WT(LB) DISP. COST <br /> CHRMICAL CONST[TUHNT Ph.,BTC. CLASS WASTE CODE L CONT TYPEN,17B AM IJW F r hwm <br /> METHOD OF PAYMENT: CASH O CHECK'. CHECK NO. Z2 ct TOTAL PAID$ �S.J <br /> PHILIP TRANS&RBM 3D CHECK-lN ATTENDANIS INITIALS DATE <br /> PSC-207 xavos,II CHECK-IN RECEIPT <br />