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395'VIES CF ANNEL ROAD <br />H -i ICiA, CA 94510 <br />077) 748-3040 <br />EtMILONMENGIL MMCM <br />GROU11 <br />WfA�fRegipp <br />CONDITIONALLY EXEMn SMALL QUANTITY G <br />CHECK -AN RECEIPT AND CER -9 MCA7CION <br />0 <br />Date of Event: fchr}Q, ) � " <br />Tmres <br />TO RE CO AULETED 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 P.emediatioa Inc. Conditionally Patempt Small Quantity Generator Waste Acceptance Program. I fiuthar certify that I <br />am a Conditionally Exempt Small Quantity Generator as defined by 17edet-al and California State regulations, and this quantity of vaastc <br />does not exceed the specified limits foe 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 hamrdcus waste manifest and comply with other state regulations <br />as appropriate. <br />CONIPANYNA3pE: <br />COPPANY ADDRESS: -7 <br />CIT'(, STATE, ZIP: (�J <br />COWANYPHONEt ( ) <br />TO <br />MET1110D OF ?A jTYXINT' <br />CONWANYREP: <br />EPA 'ODtf: <br />SIGNATURE: <br />T%TLE: I cS M <br />.YN <br />I & REMEDIA <br />CA Sp`� c1mcX B CMCK NO. - <br />PcILI7 TF yNS �� RETS^ Chi: C,{ -IN AiT�r�i'zi.A�I'rS INIT1Ai.3 <br />PS --207 Kdv IUIIO <br />DATE: <br />DATEl�' l�(Z <br />E+MCK-1N P.ECEIP i <br />