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535 GETTY COLM'' SUITE H <br />BENICIA, CA 94510 <br />(877)748-3040 <br />ENVIRONMENTAL SERVICES <br />GROUP <br />Wenem Region <br />Date of Event: <br />Timc: <br />Informed: <br />Times Participated: <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 />COMPANY NAME: L -% ( <br />COMPANY ADDRF,SS� L (Z)C-- <br />CITY, STATE, ZIP: .��;� la'6 �-)A Cis <br />COMPANY PHONE: v o-cq� !S 3 � " a IUD <br />COMPANY REP: C' <br />EPA ID#: <br />SIGNA`T'URE: <br />I7TLE:�}�� �� CRATE: <br />TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION <br />C}�LMICAI. CONSTITUENT Ph., ETC. <br />HAZARD <br />CLASS <br />AH <br />WASTE <br />STATE <br />CODE <br />S/ <br />L <br /># OF <br />CONT <br />CONTAINER <br />TYPE/SIZF. <br />WASTE <br />AMOUNT <br />WT(LB) <br />DISP. <br />MP: C}[ <br />COST <br />-11 <br />LYJ <br />C <br />METHOD OF PAYMENT: CASH CHECK ❑ CHECK NO. ' <br />PHILIP TRANS & REM -ED CHECK-IN ATTENDANTS INITIALS �� <br />TOTAL PAID S <br />DATE <br />CHECK-IN RECEIPT <br />PSC -207 P.EV 12/06 <br />