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1" 4 <br /> I;a535 GETTY COUR1;SUITE H Date of Event: <br /> BENICIA,CA 94510 Time: <br /> (977)748-3040 Informed: 7t 2718t-1 <br /> ENVIRONMENTAL SERVICES Times Participated: <br /> GROUP <br /> West=RCgion <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 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 /> I r <br /> COMPANY NAME: . '_ COMPANY REP: , t <br /> COMPANY ADDRESS: ( ] ,��Z EPA ID#: ( JyZI , <br /> CITY,STATE,ZIP: ' - ;) �) SIGNATURE: l <br /> COMPANY-PRONE: 6 Z 'TITLE: DATE: ! X11 <br /> �'` ,fit✓�" <br /> TO BE COMPLETED BY PHILIP TRA MPORTATION&REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD All STATE S/ #OF CONTAINER WASTE WT(LB) DISK COST <br /> CHEMICAL CONSTITUENT,Pb.,ETC. CLASS WASTE CODE L CONT TYPE/SIZE. AMOUNT META <br /> 1 <br /> METHOD OF PAYMENT: CASH Q CHECK ❑ CHECK NO. � TOTAL PAID SJ ` U <br /> PHILIP TRANS&RENTED CHECK-IN ATTENDANTS 1NITIALS _� C _ DATE �� I <br /> PSC-207 REV 12/06 -- ---------- ---- CIIECK-IN RECEIPT <br /> r 1 /—A A 1�If1l .i?i l <br />