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11955 WI41'1'9 0.00K WAD ihac U, P.veoe V') // — — <br /> RANCHO CORIIOVP —It 95742 Tura:: <br /> (91fi)]51-11980 IIIfdWCd: <br /> EN91af/N81PlI1W.588t[®.R TInIeR Participated: <br /> . . .._... GBOUP <br /> W.a<a.A.abe. <br /> CONDITIONALi Y EXEMPT,SMALL QUANTITY GENERATOR WASTE <br /> CHECK-fN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERAl'OR: <br /> I certify that the following information iR correct, and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Luc. Conditionally Exempt Small Quantity Generator Waste Acceptance Program_ 1 further certify that I <br /> am a Conditimtally Exempt Small Quantity (icncretor as defined by Federal Rud California State regulations,and this quantity of waste <br /> dous not exe" the specified limits for the type of waste being disposed. If this waste is later found to cauc:d small quantity limits or <br /> contain materials not accepted under this pr1,'rem,I agn:c in,cumplute a bazardous waste manifest and comply with otlici state rcgulatinne <br /> as appropriate. <br /> COMPANYNAME; IJ J ' ' ` I ' COMPANYREP::) <br /> COMPANVADDRIUSS: 'S t'W4,4- �fifi'(�r -50h EPAID#: #9-'#94K'o <br /> ary,S'I'ATTS,),IP: (� lCA C�� (7 C�� 6� SIGNATURE: <br /> COMPANY PHONE: Qp9) < CJ'd�� ' TITLE: �J C!/t%/ 'P ,i" 1k IV <br /> Z <br /> TO BE COMPLE'T'ED BY POTLYP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> 6131,1I31t.AL WASIff U0=1TION ILt7=1) All STATE S/ 7 O 17.ONTA1NF.tt WASTH vn'(I.n) n(SP. COR'I' <br /> renehacAL CONST C. C WASTE COnP. 1. CON TYPFJSIZII AMMINT MUr1I <br /> n QIP <br /> W ►titrJ 0 / dU2 ° c0� <br /> AA <br /> 12- <br /> HI <br /> 2) 9 201 <br /> \L 1 iEjLTH <br /> METHOD(W PAYMENT: CASH ❑ CHUCK ❑ CHUCK N0. 'TOTAL PAID <br /> PHILIP TRANS& REMED CHECK-1N ATTENDANTS INITIALS DATE <br /> 1'aetzu, Id --� .—_ _ Cp� CHECK-IN RECEIPT <br /> �5 Credit Card:,Fnding In 0 <br />