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vULcU IeVU. IUp rpt. LUy-4b25-5b/L p."I <br />Zvi �v� ..v i.. rra iJ: v � t'rsA I I �QQZ/QQZ <br />6 � ` <br />11853 V/11frE [LUCK ROAD <br />RANCHO CORDOVA, CA 95742 <br />(916) 351-0990 <br />YMONMliN AL ELMCSES <br />GROUP <br />Wca e0Mitrgb® <br />mI <br />PO -1 <br />!' <br />Dec of Event: <br />Time: <br />Informed <br />Times Participated: <br />• ; '• ' 3 1 ITY GENERATOR; <br />I cortify that the f0110wing information is currcet, xn <br />ansportation and Remediation htc, Conditioual'ly Exempt S <br />r a Conditionally Exempt Small Quantity Generator as def <br />es not exceed the Specified limits for the type of waste he: <br />stain materials not aoeapted under this program, l agree to c <br />appropriate. <br />)WA.NY N, <br />IMPANYADDRESS: <br />TY, STATIC, 21P: <q4p r LU.I . r <br />►MPANY PHONP" <br />10 Cl <br />AM P1101 Zj1 <br />®� 26,20z <br />I Tcad and understand the rzquirements for parlicipaiion in the I'hiGp <br />uantity Generator Waste Acceptance Program, I further certify that I <br />Federal and Califonzia State regulations, and this quantity of waste <br />Fosed. If this ante is later found to exceed small quantity limits or <br />e a hazardous waste manifest end comply with other state regulations <br />COMPANY REP: <br />EPA ID#: <br />SIGNATURE., <br />TITLE: DZ DATE; 2 to— 'Z <br />OTIM <br />omm' <br />'aim <br />MINE <br />�IMEn���■�r�■rrrrr <br />MINE nNo� <br />r 11001 <br />MEN MEN <br />.1P TRAINS & RBMED CHECK-INATTENDA.NTS 11'azT4s DATE ( 4 "/Lo <br />