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v"/.17V! Uwwrl I;;. &Y rftA <br />vJ0 OZ/ 0 0 2 <br />11855 W= ROCK ROAD Date of Evcat: bf"&K Irl, <br />RANCI 10 CORDOVA, CA 95742 'rim: <br />(916) 351-0980 informed: <br />ENVUMMMU1, SIMM -04 Tunes participaltd: <br />- GROUP <br />Wwu. Regin. <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHE CK -IN RECETPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />I certify that the following information is correct, and I have read and understand the requirements for participation in the Philip <br />lkwuportation and Reinediation Inc. Ctmditionally Exempt Sinall Quantity Generator Waste Acceptance Program. I further certify that I <br />am a Conditionally Exempt smau Quantity Generator as defined by Federal and California State rcoationi, and this quantity of waste <br />does not exceed the specified limits for the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br />contain materials not accepted under this programa, J agree to complete a hazardous waste manifest and comply with other state regulations <br />w appropriate. <br />N zy <br />1 5 <br />METHOD OF PAYMENT: CASH 0 C13liCK* CRECKNO. <br />PMLIP TRANS & REMED CHECK-IN ATrJ3NDANTs iNaws livi <br />