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From: 07/15/2011 13:02 #694 P.0021003 <br />395 WEST CHANNEL ROAD Datc of Event <br />13MCIA, CA 94510 'fine: <br />I ,, ?' ' nn� <br />fotrtc.. <br />50(877)748-3040 <br />GROUP Times Participated: <br />Wcstvn Rte+= <br />CONDITI NALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />C4 -IN RECEIPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR; <br />1 Certify that the follow" g information is correct, and I have read and understand the requirements for participation in the Philtp <br />Transportation and Remediation�nc. Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I fur•tber 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`7t' oy-)I I S <br />COMPANY ADDRESS: 10-51 C--' . mUYCo S� - <br />CITY, STATE. LIP: ftc.Ekv) X20 5 <br />COMPANY PHONE: QOM'!) 43 67 V <br />COMPANY REP: i.-.aYa/1d <br />EPA IDN: L - <br />SIGNATURE <br />TITLE: ��� 1✓2 DATE: d — <br />v <br />METHOD OF PAYMENT: CASH 0 CHECK lil CHECK NO M-7 TAL PAID S � U ` <br />PHILIP TRANS & REMED CHECK-IN ATTENDANTS INITIALS AT. <br />rsC•sot REY M10 CHECK -1N RECEIPT <br />