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From: 07/26/2011 12:46 #747 P.002/002 <br /> 6M395 WEST CHANNEL ROAD Date of Event: <br /> BENICIA,CA 94510 Time: <br /> (877)748-3040 Informed. <br /> ENN'tRONMENTALsERvtCES Times Participated: <br /> GROUP <br /> WCSE—Repot) <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 1 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 I <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 being 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: J U�LlCa4 YS, .— COMPANY REP: U IIf 6,E-.,/1 l Co <br /> COMPANY ADDRESS: &)L"nC)p S k EPA ID#: C 'C <br /> CITY,STATE,ZIP: :Y e Cnvy\p CA CA&Z- 1 SIGNATURE.- <br /> COMPANY <br /> IGNATURE:COMPANY PHONE: (� 1 - (5? TITLE: DATE: 1 �� <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD Ali STATE S/ NOF CONTAINER WASTE WT(LH) DISP. COST <br /> CHEMICAL CONSTITUENT Ph. ETC. CLASS WASTE CODE L CONT TYPESIZE AMOUNT METH <br /> LAr <br /> 1 <br /> METHOD OF PAYMENT: CASH ❑ CHECK (]rCHECK NO.01i&6 TOTAL PAID,.$ <br /> PHILIP TRANS& R.EMED CHECK IN ATTENDANTS INITIALDATE <br /> PSC-207 RFV 10;10 CHECK-IN RECEIPT <br />