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■: ei2512014 wt;o 15103 17Ax V< iv- aa> <br /> ■ <br /> �■ 11855 MUTE ROCK ROADA j !VC Dalc of Evcnt: �7 12 6,11V <br /> RAN(:110(:Oltl)OVA,CA 95742 't'irac' rr O0�7iy <br /> (910)3 510980 t 1 �►r t��rntcd: ` <br /> IiNVIItptVtgl:lYiA6tf1(Itv1CJ �t � � �T��nE dramd: <br /> cnour <br /> RECEIVED TIONALLY EXEMPT SMALL(QUANTITY GENERATOR WASTE <br /> r� CIWC'K-IN REMPT AND CCRTI ICAIYON STATEMENT <br /> TO IW COMPLETED BY GENERATOR: <br /> ENVIRONMENTAL HEALTH <br /> PER &R"L#f0ftwiug intfotznation is cot7ect,and I have read And understand the requimm"tvr participation in the Ph flip <br /> '1'muportation and Remediation Inc.Conditionally Exompt SmalI Qufttity Ceneratoc Wwlce Acceptance Program. I furthw certify ffiAt I <br /> am a Conditionally P-x mpt Small Q=itity Gem-ator as defined by Federral and Catitomia Stile regulations,and this quantity of wflsto <br /> does not exceed the specified limiter for the type of waste bebig d1sposed. If this waste is later found to exceed small quantity]units or <br /> contain meerittla not accepted under this program,T agmu to compluw a hamrdous woke maniCeal and comply with othor stato regulations <br /> as ttpproprinoo. <br /> COWIMNY NAM- COMPANY RIO% �u�4iq <br /> COMPANY ADDRESS: D RPA TW! <br /> CITY,STATLr,ZIP: STGNAT 1RE: <br /> COMPANY PHONE: j0�1) �Ct N TITLE DATE: <br /> (422-Z- <br /> TO BF COMPLRTrn SY PMLiP TRANSPORTATION& REM ,T)JATION CHECK-IK ATTENDANT <br /> (RNFRAL WASTE DESCtit ON HAZARD AH STATE S! k OP CONtAINM WAM WT(LS) DISI. COST <br /> C W 'T LDL•' L CUNT TYPEISIZE AMOUNT MET <br /> ENVIRONMENTAL HE ALTH <br /> METHOD OF PAYMENT: CIILCK CIIGCK N0, `10 1*0,rAL NAIll$ J 1`,00 <br /> PIIII.IP TURNS&REMED CIMCK IN ATTURDAN'1'S LN1'TLALS. UATL <br /> rsc-707 navoeni CIIPCK-IN RECEIPT <br /> Received Time Ju1. 26. 2015 2.47PM No. 9202 <br />