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6125f2014 'WHRa 13+03 Fax �� }� C <br /> 1V <br /> 11855 WMTE ROCK ROAD Dnto of Evom <br /> PAN(',]10(:OR00VA,(,A 95742 'time: <br /> (916)331-0980GROW <br /> teeforuxcd ` <br /> KNYIRQtHaitfl�r'i'M.SfSnY�Ct�i "t'in,ep t'articipnt�ad• <br /> a, �VE <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERAT a D <br /> WE REC APT AND CERTIOCSfION STATE,ME <br /> JUL .11 2nid <br /> TO DTA COMPLETED BY GENERATOR; <br /> MEf�lTgL H <br /> I certify that the Wowing informatiou is correct,and I have read tnnd understand t4 p requin;trtMh ' i �p <br /> crausportAtion and Remediation Inc,Cnttdiciona#ty Fxatnpt Small(�uarttlty Cetreratar Waste Accsptaace Yrogratu. er tltnt i <br /> am a Conditionally Excwpt Small Quantity Genet'atm as defined by Fedwal and Calitomia State reBulatimia,and this quantity of westo <br /> does not exceed the specified limits for the type of waste being disposed. If chis waste is later found to exceed stuall quantity limits or <br /> contain mull rials not accepted under this Im)grvm,T agruu to eomplatt:a hamrdous;wants;manifosi and comply with ether state regulations <br /> as appropriate, <br /> COMPANY NAME: �0 1..x&W COWANY Met% �6(�2rlitl <br /> COMPANY ADDR&SS: d f EPA TDO: <br /> CITY,STATE,ZIP: SIGNAT IRE: <br /> t <br /> COMPANY PHONE: (ZjD�( TITLE j, DATE: ,- / <br /> TO HE COWL.ETED SV PMLTP TRANSPORTATION Si REMEMIATTON CRECK-IN ATTENDANT <br /> GENERAL WASTEDESCRt1rriON ILV— X AH STATE S/ dUP CONTlIII`RBR WAbM WT(LB) DISP. (:UST <br /> CL 'S W STS (WE L CONT TYPMIZE AMOUNT Mfr <br /> M7'MOD OF PAYMPNT: GIIL'CK CIIT;CK N0. <br /> I'0 f AL NALD$ 'a� <br /> PHILIP TRANS&RT MED CIIECIC-}N A'I II NVAM S INITIALS _ DAM <br /> "C;aoT navoen, CIIF,CK-IN RECEIPT <br />