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'05103/2413 FRI 11: 37 PAX ECE1VPf- ' <br /> [�uu��vax <br /> 11855 WUMI Lt.00KROAD ! I 2 7 2014 DW*till,ftvmL <br /> I <br /> RANCHO CMDUVA.CA 95742 cu= <br /> (5►i�351.nvKn ENVIRONMENTAL Infemed: <br /> tslrttrttttrty Gaour'�lsuvtt HEALTH DEPARTMENT o 1'aWcknted: <br /> > <br /> CONDITIONALLY EXRNMT SMALL QUANTITY GENE A:rOR WASTE <br /> CRECK4N RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLE'T'ED BY GENERATOR: <br /> ACTOR: <br /> certify that the following iafcmtiladinn is wcis-. and I havc rcwl and u►u ndtlte r6WW;M=tr far pardcipation in the Philip <br /> Trx L4pa tudcm Ano-Reutsdiatloa Ittc.Gonditiomllly Exempt Srnnil Qawgity Genamtor WmicAemptu=Pmgrom I Turthar oariify that I <br /> am a C:mditionetly Lxmpt SsnatI fwnli[y(ic nmtnr ea dcstmcd try Fcdcral and Calif mia State regultttm$,Corel this quantity of WaM <br /> docs not rxrc;W the specified limits for the type of waste being disposed. ITUvW waste is Later fotwd to exeftd small quantity Blairs or <br /> contain materLAk i pt led ua tt'Citta prog=4 I ggrce to ctmVictc a htlxa dutw waet c maniftst Anti comply with otllor atata regulat{ons <br /> 8s apptviniats:_ <br /> COMPANY NAME; [ ' CAMI'AKY k>ad'; � `;'! (�� <br /> COWANY A DD _ EPA m#: { <br /> CI`M,NClt.TU,lift a CAs �' SIGNA'I'it t <br /> c.OMPANvMONX; { -3-�cff-) TI'F—. -7W" aAm <br /> TO,43E COMPLETED BY PWIP TRANSPORTAT,10N&RRDEDLMON CUECK-1J1 ATTENDANT <br /> Cilttdli[[AL WAFs[x.1 9CA1Pl7L2TV -HA7,Ait11 AH STAn st #a--- Cdghohuta WASl1t iV fYL!!) U13i+ CCAS 1' <br /> CALGClA25`l77YlN Ptr Y' 1 W ^ <br /> WME <br /> y <br /> 2G". <br /> METHOD UR PAYMENT: C.ASN © CrVCK a CHECK NO. ) TOTAL PAM I <br /> P2-11LLP TRANS,&RP.MF.A n, M,(K J ATI'.PNDANTS I'ALS aILLe , DAf'F :Zy�a- f <br /> PSC-267 Ravrortt CHECK-IN REGEIPI' <br />