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04/26/2011 06: 28 2094662x'" STOCKTON AUTO PAGE 02/02 <br /> sm535 GFTTY COUKr.SUITE H Da' of Event: <br /> RENICLt,CA 94510 <br /> (977)749-3040 Timc: (� <br /> L,formcd: <br /> E OWNEENTAL P 9rSRVt["F?` Timm Participated-_ <br /> Wcetrm Reglon <br /> CONDITIONALLY EXEMPT.SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CE,RTAS ICATIO]N STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and I have read and understand the rcquiremefats for participation in the Philip <br /> Trarisportation and Remediation Inc. Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> am`a Conditionally Exempt Small Quantity Generator as defined by Federal and California State rcgulatious,and this quantity of waste <br /> does not exceed the specified limits for the type of waste being disposed- ]f this waste is later found to exceed small quantity limits or <br /> contain materials not accepted under this program, I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> CONVANY NAME: ailY11'ANY REP: <br /> COMPANY ADDRESS: '54- EPA ID#: <br /> CITY,STATE,ZIP: c C, <br /> SIGNATURE. <br /> COMPANY PHONE: (��I) �L�-Sri $�O — TITLE: <br /> DA'Z'E: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION&REMED;IATION CHECK-IN ATTENDANT <br /> GENERAL WASTE I)ESCRTPTTON HAZARD AH STATE St #Ot: CONTAMR WASTE WT(LD) DISP. COST <br /> LFiEUCALCONSTITUENTPh, ETCJ CLASS WASTt. CODr; L CONT TYPEISIZE AMOUNT MF?T}[ <br /> tv <br /> METHOD OF PAYMENT: CASA El CHECK Q CHECKNa TOTAL PAID g <br /> PHHILTP TRANS &REMED CHECK-IN ATTUNDANTS -1-L) <br /> Tldl'I7AI,S DATE <br /> t'Sr_.207 Rev 12M6 CHECK-IN RECEIPT <br />