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— GROVP — <br />rar Rapm <br />Is <br />395 WEST CHANNEL ROAD <br />HEMCTA, CA 94510 <br />(877) 748-3040 <br />Date of Event <br />Time: <br />Informed: <br />Times PaRicTated. <br />CONDITIONALLY EXEMPT SNLAI.L QUANTITY GE=NERATOR WASTE <br />CRECK-LN RECEIPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />I certify •bat the following information is correct, and t have reed and understand the requirements for participation ir. the PE;p <br />tansportation and Remediation Inc Condiconally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that : <br />am a Conditionally Exempt Small Qt:antity Generator as defined by Federal and C.alifornis 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 axeeed small quantity :imits 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 appropri". <br />COMPANYNAME: �(�('1 ThC CX-stJl rA,& + <br />COMPANY ADDRESS: or <br />CITY. STATE, ZIP: <br />COMPANYPgOiYE: <br />CONIPA.NY REP: mM,iL CQYAYJtA <br />EPA IDM: <br />SIGNATURE: - - <br />TITLE: ! - DATT.: <br />i • 1 ,t 1' 'i •I Dill• 1 <br />INN0R <br />.-. •. � W. <br />I___ <br />-_■____L-_-_1 <br />fro <br />.• <br />i <br />MIN <br />� <br />III <br />IME <br />I �{ <br />-©s, <br />t <br />___ <br />__�-- <br />r . a_.. M.. •.21INNE <br />=1 <br />MEI <br />O <br />10011M <br />HIM <br />_ <br />MIMEMEM <br />11M <br />INIMIMEEN <br />HIM <br />=1 <br />IME <br />als.THOD OF PAYMENT: CASH U CHECK ❑ CHECK NO. <br />ICTAL PAiD S`�---_--''— <br />pF kLIF TRANS 8r READ CHECK-IN' ATTEIPMAN-CS INI T LI LS DA -1= - <br />-�c+c- xnv I W i 0 CHECK-IN RECEIPT <br />ci <br />