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Oct 01 14 07:13a <br />amI 1355 WHITE ROCK ROAD <br />12ANCHO CORi?OW, CA 95742 <br />(916) 351-0950 <br />aNV RONM ENTAL SEMCES <br />RECTIVEr <br />(Date of Event: <br />OCT 01 2014 <br />informed: <br />ENVIRONMENTAL I�EAL�I"`ic'guted_ <br />p.2 <br />- GROUP <br />tVe.>rro DEPARTMENT <br />CONDITIONALLY EXFMTT SN(ALL QUANTffY GENERATOR WASTE <br />CHF,CK-1N RE, CEIPT AND CERTIFICATION STATEND:NT <br />TO BE COMPLETED BY GEN-ERATOR: <br />I certify that the following information is correct, and J have read anal undefstand the requirements for parti� f C tt>atPbil I <br />Trausportation, andRemediatidn Inc_ Conditionally Exempt Small Quantity Generator Waste 4cxeptaacc Program. <br />am a Conditionally Fxerupt Sma(1 Qu9ntity Generator as defined by FOderalf � wee is lutes found to exceed small quantity limits or <br />does not excoed d1c specified limits for the type of waste being disposed, <br />contain matc.!ials lot aeeepted under this prng am, I agree to complete a hazardous waste Manifest and comply with other state 7co tlatiuns <br />as appropriate. <br />C0MJ-ANY N,UME: I 1 i f <br />CO M PAN Y ADDRESS: (oz,, I, ;' {q <br />rrrv_ S'T'ATE. ZIP: <br />COMPANY PHONE: (20`t) . `�Gl� = � <br />COMPANY REP: <br />EPA ID#: <br />SIGNATURE: / <br />TI'T'LE: / DATE: -7 <br />t L. TOTAL PAID <br />: TkTDD ()FFAYIViI~1�T: CAScs. Q CHECK a CJECK NO. �. <br />ATE <br />PI�III,iP TRAt+iS & REMED CI-jEcK-TN ATTENDANTS INMALS - <br />CD�. � —�- <br />CRE-CK-IN RtC>;JPT <br />�REUCT Q;DEMDWO IN <br />