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I <br /> i <br /> 60BE WEST CHANNEL ROAD Dace ofEime: - 1 I.QI�.I . <br /> BEMCIA,CAA94510 Time: <br /> (977)748-3040 Informed: <br /> FNNIRO\ME\r'ALSLM7CFS <br /> GROUP 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 Remodiation 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. 't,, <br /> COMPANYNAME:�(YM(qAa'kGN J-('-nm COMPANYREP: �(o'e <br /> COMPANY ADDRESS: �t�S ,(1{g '�-EIf VI J 1 -'Ffa„L_ PA0. 1D#: C �,(}�Q L- 9�S' G' <br /> CITY,STATE,ZIP: K 11 G,.y OiSt13 t`tuC/ IGGdNATURE: i <br /> COMPANY PHONE: R(A) 0100 60 CI(, TITLE: ^ / DATE: — <br /> i <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION &REMEDLA.TION CHECK-IN ATTENDANT <br /> GENERALWASTEDFSMUPTION HAZARD AH STATE SI #OF CONTAD7ER WASTEWT(LB) DISP. COST <br /> CHEMICAL CONSTITUENT'PIL ETC. CLASS WASTE CODE L CONT TYPEISUE AMOUNT MEM <br /> e O5O Cans <br /> AhS U " 0 L( ^ ' <br /> 1 <br /> 1 210 <br /> El <br /> � �� ��� <br /> METHOD OF PAYMENT: CASH CHECK CHECK NOY <br /> . ou 1.v0 TOTAL PAID <br /> �jz:7� <br /> c <br /> PHILIP TRANS&REMED CHECK-IN ATTENDANTS INITIALS � Dp'1E -1—1,� <br /> ncaar asv umia CHECK-INRECEIPT <br />