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0S/01/2011 FRI 11.- 37 PAX RECEIVR, <br /> Wtuux uui <br /> ttssswtrxROCK ROAD 27nm.,far. t / / <br /> RANCHO COROt>YA,CA 9:5742 7n=- <br /> (51111r 33t.tMNti ENVIRONMENTAL larounud; <br /> tslvvntONattawtAr.tl:suvtras HEALTH IMPARTMENT 1""5 v nic pate" <br /> GROUP <br /> waaw t'W� <br /> CONDITiONALLY RXPMPT SMALL QUANTITY GENERATOR WASTE <br /> CkI1ECX4N RECEIPT AND CERTIFICATION STATEMFNT <br /> TO BE COMPLETED BY GMNEPATOR: <br /> I cer UY that the following infutm>aian iN urrrcct,and l have Tcad and understand the regmaemmu for parlacipation in the Philip <br /> Tumpmtadon andRemWiatloa hm CeaditiomIly Exempt Small(hiawitg Geuemw Wasic Aempmwo Pmgram- I farther aeHlfy that I <br /> Im a CDaftionally Lxwmpt Srmll Qianlity ticacratnr as demcd by Federal and California State regulations,mW this gwntity of waste <br /> di)cs not�cced the specified limits for the type of beiag disposed. If this wwto is later fatuld to excoed small quantity IWI*or <br /> contain materlals-gmtaeeepted under This prognm4 l 9grec to etwtplete a har dous wastr mamfrst and comply with otlaor state regulat[one <br /> 8s appropriate <br /> GQMPAiVY lYAMH: . CAMs-ANY inw; <br /> CONf!'ANYADD �. � ti SPAib#: 61,:J <br /> Grt•Y,S ATAt zw: a G4 41%0-3 �La j�� SIGNATM: <br /> r <br /> coMrAxYrnorx: WLE: <br /> TO BE COMPLETED BY PHiLIP TRANSPOitTATIO>•T do RFMEIOWION CHECK-IN ATTENDANT <br /> ()tiN/iv sl WAFS'1'H MC;RIP71ON 'PW.ARD AH MUS St U Or COPrl'AIIM -WAS11 W l") UlSP, IXhCr <br /> CALt:'nN5!'t'/'F:H pie: l' ,1 W <br /> �., <br /> 21VC <br /> METHOD URPAYMENT; GASH © CIiFCK 13 CIIliCTCNCI. 1 f—, � TCITALPAiR3�. <br /> PHILIFTRANS&RRMP.AC,PF,C7 TtiATT-l'14DANTSMIALS dlc DATE, <br /> psem nava tt CHECK-IN RECEIFF <br />