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VV Za/Z01a PRI 9: 42 FAX <br /> '77 ®001/001 <br /> M311855 WIIITC RICK ROAD Date,H'I?vmu: O � �7 <br /> RANCHO COItUUVA,(;A 95742 Timu: <br /> (916)351-0980 M <br /> ENVIRONMEWALlitimCES Infomtcd; <br /> uuuur—.. -. . lima Participated: <br /> wtwt Pw" <br /> CONDITIONALLY EXEMPT SMALL,QUANTITY GENERATOR WAS'T'E <br /> CJUb CK-IN RECEIPTAND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENLRATOR: <br /> T certify that the following information is%omen,and I have mad avid understand tyle mquiremeots for participatiuu iu d(c P)utip <br /> Trattsportalion and Remediation inc.conditionally F,xelnpt Sula11 Quandty Generator Waste Acceptance Fragram. I further certify that 1 <br /> am a Conditionally Exempt.Small Quantity Cienerator Its&-lined by Fedcrai mid California State Iogulahorls, Bud this quantity of waste <br /> does riot exceed the spuciticd limit.% for the type of waste being disposed. If ads waste is tater round to excccu smart quantity limits or <br /> contain niaterial.s not accepted under dus program,l agree to cu nplew,a ha'r trdlmn waste ulanifeat and comply Willi other state regulations <br /> as appropriate. <br /> COMPANY NAME: (� ( )� ( � (ol�urY1 (:(IMAIANY REP: 6ANl. <br /> rnmrANxwnnaass: nK 1A 26 (fir t° VPA u)a: <br /> C.rrv,SrA't•6:,ZIP: SIGNATtlRE: -- <br /> COMPANY PHONit: (74q) TITLE: <br /> 7'O BE COMPLETED BY PtM,YP TRANSI'ORI'NfION & REMEDIATION CHECK-IN ATTENDANT <br /> (IIINY.RAL WAXTR D1.1(:Itit'T(f1N llAZARD All STAI ii R) A(IF fYIN'I'AlNfta WAY)' r.p <br /> CIItIMIOAI.CONSTMIRvM ,. T' W 0 C L CONT •IYYI%I-Hi A AY)' 'I' Wr ) DISE COST <br /> uocts� q Y , 11 <br /> 6 V <br /> Y <br /> ijAj <br /> ALTH <br /> E T <br /> METHOD OFPAYMFNT: CASA U CIIL'CK (3 CI119UKNO. •t. TOTA1.PAIDR <br /> PRIM PTR ANS& RFMFT)CIIFCK-INAITENDANISINITIALS _ DATE <br /> cREDrr CARD t71DiNO1N 53 7 i CHECK-rN RRCEIPT <br />