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09/08/2011 09: 13 2093340632 GREGG PROPERTY SERV PAGE 02 <br /> so395 WEST CnANNEL ROM Datc ofEvcnt: ri 1 <br /> R1FN1CJA,CA 94510 Tune' �h <br /> (977)la8-3040 Wormmd: �� <br /> LfitsNTAL36RdtCT;S Times Panicipated: <br /> GttO13P <br /> 9ota�s A4ier <br /> CONDITIONALLY EXEMPT'SMALL QUA.NT'TY GENERATOR WASTE <br /> C,HFXK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> eertify that the following inform tion i�correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Rensediation Inc.Conditiolsal)y Exempt Small Quantity CtWWRTOT WasteAceeptance Proffam. I further certify that I <br /> alt} a Conaio"Wly Exempt Small Quatatity Generator as definotd by Federal and California State regulation,,, and this quantity of waste <br /> does not exceed the specified 1ia11ta for the q"of waste being disposed_ If this waxte is )atsr found to exceed small quantity limits on <br /> contain materials not accepted undw this program,)agree to complete a tuuardous waste manifest and comply with other state regulatious <br /> as appropriate, <br /> COMPANY NAME: COMPA14Y REP: ISe n <br /> COMPANY ADDRESS.- EPA IDN: O d 60 5S3 S <br /> CM,STATE.7JP: S SIGNATURE: <br /> COMPANY PHONE: (WO) Tins. �� DATE: <br /> TO SS COMPLETED BY PWUP TkANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GFROU L WASTE D&SCIt"ON HAZAXA AN STATE S/ Nor COWTAarER WASTE WT(LB) DISP. COST <br /> Ph W L C T AN <br /> T <br /> 10 <br /> METHOD OF PAYMENT: CASH O CHECK 0 CHECK NO. TOTAL PAIb S r <br /> PHILIP TRANS do REM FTI C}IECK-fN ATTENDANTS fMTIALS DA <br /> psc-101 RRY WOO CHECK-IN RECEIPT <br />