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From: 07/26/9011 12:46 #747 P.002/002 <br /> 395 WEST CHANNEL ROAD Date of Event: <br /> BENICIA,CA 94510 Time: an cA <br /> (877)748-3040 <br /> Informed: <br /> ENMONMENTAL SERVICES Times Participated: <br /> GROUP <br /> ulcsru Rceva <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT 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 /> Transportation and Remediation Inc.Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that 1 <br /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, and this quantity of waste <br /> does not exceed the specified limits for the type of waste beim disposed. If 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 /> COMPANY NAME: iJ � L )i COMPANY REP: V bV, <br /> COMPANY ADDRESS: ;9 ' S r` a���tA—���—Sk EPA ID#: C <br /> CITY,STATE,ZIP: }L Pm�n Cnt 11 SIGNATURE: <br /> COMPANY PHONE: (yy;v q 2 TITLE: I ,� p '�� DATE: <br /> © ' <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DISP. COST <br /> CHEMICAL CONSTITUENT Ph- ETC. CLASS WASTE CODE L CONT TYPESIZE AMOUNT METH <br /> LAIi , <br /> I Ci C4 <br /> METHOD OF PAYMENT: CASH ❑ CHECK CHECK NO.04& TOTAL PAID$ <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIAL DATE <br /> PSC-:or &EV W10 CHECK-IN RECEIPT <br />