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395W1i.9TCHOROAD • Dale of Event: a� <br />BEMCIA, 94310 Time: <br />(877) 948-30404 0 lnfonned: <br />ENVIRONMENTAL SERVICES Times Participated: <br />GROUP <br />'k .Rego. <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 farther certify that I <br />am a Conditionally Exempt Small Quantity Generator as defined by Pederal 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: -_--- IAVaT YhS T%ALlay(tS <br />COMPANYADDRESS: Li 4 \ (k <br />CITY. STATE. ZIP: 'a .�, � , i�iWr 53Vy <br />COMPANY PHONE: <br />COMPANY REP: t ' \(."k Cpl/ dbw <br />EPA IDM: <br />SIGNATURE: <br />TITLE: DAfF: 4 - j 7— <br />TO BE COMPLETED BY PHI LIP TRANSPORTATION & REMEDIATION CHECK-IN A'T'TENDANT <br />GENERAL WASTE DESCRIPTION <br />CHEMICAL CONSTITUENT Ph. ETC. <br />HAZARD <br />CLASS <br />AH <br />WASTE <br />STATE <br />CODE <br />si <br />L <br />k OF <br />CONT <br />CONTAINER <br />TYPHISIZE <br />WASTE <br />AMOUNT <br />WT(LH) <br />DISK <br />METH <br />COST <br />„� <br />fZ <br />Io TX. <br />to <br />_ <br />t <br />_ <br />ao <br />f a t - <br />METHOD OF PAYMENT: CASH 0 CHECK 0 CHECK NO. _ TOTAL PAID S �— <br />PHILIP TRANS 8C REhffiD CHECK -]N ATTENDANTS iruTTAIs <br />DATE —2-2� <br />t <br />rsC-mr a6vian)� un -00+ CHECK-IN RECEIPT <br />�a,S�ccl�u:C � U31 i z <br />8a7 (,v <br />