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MAR-12-2014 88:01A FROh1: TD:468.3433 F'.4=4 <br /> • VV L."AVLQ Wvm Wo ML FNA Wvv., W.- <br /> 11 M55 WI 11TH 110(,K ROAD Detr of Rvent: l Z IT <br /> It,ANCHO COWOVA,CA 45742 Tllrnv: — <br /> (716)3.51-0980 lufaqucd: <br /> 1111MIONWWTALSERVICES Times t'artleippted! <br /> e3nUUR E <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATORASTL+' CEI r,/ <br /> ED <br /> CTIRMIN RECFT(''1'AND Cj'rRTTr1CA'f.'I0N$1'ATEMYN <br /> MAR` 12 2014 <br /> '1.O KN,CO1vI1'LE"11,111 BY GENEIWOR; <br /> -ENV �ppp�M�TAL <br /> I certify that the following information is convet,and I lwve tend and understand dta mqulrautagtt for paltiici atl'ion{ 1TiieYllSttti-NT <br /> Trumportafion and Remediation Inc.Conditionuily F.xompt Small Quantity Gencrttor Waxw Acceptance Program. I further Heftily that 1 <br /> tun a Couditioually Exempt Small Quantity Geutmor ns defu►ed by Federal ntld CaLforuin State regulations,and this quantity of waste <br /> tlms not exceed dlc xpeciticd limitm for file type a1'waste being dimproscd. if this waste in later Ibund to exceed►Untill quantity lilnitN or <br /> :ontaW materials not accepted under this;program,I agree to complete a hazardous wncte mauifest and comply with other stato;rognll►tions <br /> as appmr1riulc. <br /> COMPANYNAME: f/ 404ff0a!0 COMPANYRIP: g0h <br /> COMPANYADDRESS. EPA IDN: � <br /> CITY,STATE,ZIP: Gly f �b'Zoy SIGNATURE., r�9- <br /> COMPANY rIIUNQ: (2104) / // TITLE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION&REMEDIATION CHECK-IN ATTENDANT <br /> 06141 RAL WASTF nEMIMON WAIM AH STATR 81 f OF WNTAINPR WAS-CA WT(I.R) m'P. t;t T <br /> �R",, A1. . T Ph, t:1.A $ W,4,qTFLt:OAA 1. (�NT TYPW91ZP, AMMINT WIN <br /> til rrsrs., I,L,W 6 ' D .s <br /> R <br /> METHOD OF PAYMENT: CASH ('HECK O CHECK NO, TOTAL PAID S �' <br /> PHILIP TRANS&REMET)CHECK-IN ATTENDANTS t'NTTiAI.S HATE <br /> C IIL'C:IL-1N RliC:LLPT <br /> I'MA07 aAv oral <br />