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M=FMB <br />395 WEST CAL ROAD • Dam of Event <br />SMCL4, CA 94S 10 <br />(Srl) 748-3040 Time: - it <br />¢nmao mrerrru setrnr,¢s �a <br />caovr Timms Rrticiprtad: <br />uturr,, aq.. <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTWICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />1 certify that the following information is correct, and I have read and understand the requirements for participation in the Philip <br />Transportation Inc. Cemditianelly Exe <br />io and Remediation Impt Small Quantity Generator Wan Acceptance Program. I htrther certify that I <br />am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State tegulapons, and this quantity of waste <br />does not exceed the specified limits for the type of waste being disposed If this waste is later farad to exceed small quantity limits or <br />coatnia materials not accepted under this program, 149" to complete s hazardous waste maadint and comply with other state re lations <br />as appropriate. ge <br />COMPANY NAME: �46CC. lrrd,&•f15'OMPANY REP: ryNa,..k-C(WdJA0 <br />COIPANYADDR&S5: Qt{U .raoOr EPA WO: <br />Cr", STATE, ZIP: 'l i�r PC g53uq SIGNATUM: •.�", <br />COMPANY PHONE: ( Trm: DATE: 7 <br />METHOD OF PAYMENT. CASH ❑ CHECK 17 CHECK NO. <br />PHILIP TRANS Jc REMED CHECK -!N ATTENDANTS IM?iALS <br />PSC -20,i!! '�� <br />PS <br />Rev lalo <br />TOTAL PAID S OW L�q.gU <br />DATE C4 I Z <br />CHECK -CV RECEIPT <br />. , _ <br />■►,rte■■■■� <br />- : <br />�■■�. <br />METHOD OF PAYMENT. CASH ❑ CHECK 17 CHECK NO. <br />PHILIP TRANS Jc REMED CHECK -!N ATTENDANTS IM?iALS <br />PSC -20,i!! '�� <br />PS <br />Rev lalo <br />TOTAL PAID S OW L�q.gU <br />DATE C4 I Z <br />CHECK -CV RECEIPT <br />