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03/2b/2015 TxU 15: 52 PAX ®001/001 <br /> 11855 w171TE MOCK ROAD Date of Everw <br /> ItANC1IU t.Y1l UVA,LA 95742 Time: URI am� <br /> (916)351-0980 GdoTi m! <br /> mvvTltttNmnNrnr.slsnvrrns <br /> /:a11110 '[Touts Penlciparcd: .�M ...----- <br /> nM.m Rrainn <br /> CONDITIONA LY ENXMPT SMALL QUANTITY GENERATOR WASTE, <br /> CHECKIIN RECLIPT AND CERTIFICATION Sum,mLNT <br /> TO BrCOMPLETF..D DX GI?NE'RATOIti <br /> I certify that the followhig information is cnrmct,and I have read and uuderstand the requilvinents for PaTbaipation in the Plillip <br /> 7Fansportation and Iteniediatien Inc.Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> am a Conditionally Exempt Small Quantity Gooerator as defined by Federal and Califeuals State requladow,aad this quandly orwash; <br /> does not oxceed the specified limits for ire type of waste being disposed. If this waste Is later found to exceed small quantity limits or <br /> eentaill lmaterielo not-accepted under thij prugtam,.l agree.lo.coonplete a hazardous:wastemenirrst and:comply with otherstate reguladnus. <br /> as appropriate. <br /> COMPANY NAME: W- j�On Way' Tir COMPANYUP: Jordan Peterson <br /> COMPANYAnnRreSS: 221 NN- EPAll)k CAL <br /> -CITY,STATE.ZIP: -Slacklon rA 99i 005 SIGNATURE: � ��/ �4&-�— <br /> 0011PM+V PHOtYEs (209)Ii - 65-0281 TITL93 <br /> TO BE COMPLETED BY P IP TRANSPOiI7'A'i'ION &REME IATION CHECK-IN ATTENDANT <br /> OeNerus.WA93'e UaaCItlPrt 1 8_. _W f .BTATAE LI•_ Y Op cUN'mmp. - w 11 ' WT")- tDISP. T <br /> t703 .- <br /> N3TITt <br /> OL5 <br /> FluorescentlWaaa- 41. : 29 <br /> Prncr�Q--- - -3--e-- �^ <br /> 1 <br /> METHOD OF PAYMENT. CASA' ❑ CIiPCic ❑ CFIECKNO. -2L53 �5 TOTALPAMS- <br /> rZ <br /> 1•FDLII'TRANS&itmm CHK-IN,T=NDANTS INIT / <br /> IALS �l 6 e. DATE. _4. <br /> _ .-- <br /> rsc-vi. anvmun ralxCK•tN RLCEIPT <br />