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4 <br />0 <br />.535 GETTY COURT, S17E1 H <br />BENJC-IA, CA 94510 <br />(877) 748-1040 <br />WOMB <br />GROUP <br />vl�— k4m <br />0 <br />Dateof Event. - <br />Tin -le: <br />TizDw PEnjoiPelo';: <br />CONDITIONLUV EXEMPT SMALL UA:' T1 GENERATOR AASTE, <br />CHECK-IN RJECEWr -A-N7) CERITIFICA.-T-110IN SATE-IMENNT <br />TO BE COMPLETED BY-GARINERATOR: <br />I cerfii-j that theta following informadon is correct, a.nd 1have read and understand the requimjnea,is --'or PW6c4pation �-.- the Philip <br />Transportation and Remediatio-n Inc. COndhdonaRy Exempt Sarsall Qu&ntfty Generator Waste Accepianoe P_zograni. 1 furtter Ge-it'ify. that I <br />am a Conditionally Exempt Small Quantity Generator as defined by Federal and CaUbmi-q State reg Qiatioias, a -ad this quantity or Waste <br />does not exceed the specified limits for the type of wacte being disposed. if this Yvasre islater found to exceed small quantity Lim -Ts or <br />contain materials not acicaptcal under this pjografu, 1 agree to complete a hazes—ious waste manifest and c=_Ply with oilior state rem latilo,%4 <br />as appropriate. <br />. ; <br />COPAPAISFY NME* Ar Q CA '( <br />CO-MPA.NY _411)DRES& 7 el <br />CITY, STATE, ZIP; 6 VJ; <br />C0JVP.4.2NY <br />C 0 rv.LPA_TT5_,' R14P <br />F <br />P,4 LD <br />S I G11-b-Aff URE: 7-, <br />_r i'Jui <br />GENEPLA-1 lkASTB DES CRIPMN <br />gIBMJCkl_ COMM TUENr Pb— ETC.) .1 <br />RAZtPD <br />CL A RSE_ <br />JAS S Ez <br />S 71 ATER <br />CODE <br />9/ <br />L <br />OF <br />C 0 N-71 <br />CGNT_<_"7FR <br />T;PSFSTZB_ <br />-W 'TilB) <br />A—MiGUINT <br />:''Tse- <br />bl, Ml <br />cos, <br />_444 <br />17 <br />ETHOD Of PAYMENT* C.ASH� Cd:HC1KQ CHECKINO. TOTAL PAM S <br />pi-IlLIpTRAiN,S&RP-hMDCHF,CK-INAI-,'.-PND-kNTSE,HTT-ALS-d!;�:= DADS <br />?IRC -107 REV t2/06 CUCK-R' R_PCB.LP-! <br />