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11/24/2014 ON 8.- 27 FAX. 0 RECEIVEt <br /> I ISSS WRITR ROCK LCOAD Date of EvonL: MN. 2(b.2014 <br /> RANCHO CORDOVA,CA 95742 Time: - <br /> (916)351-MO Informed: <br /> DEC 04 2014 <br /> UNVbt0NMRNTALS EMCgs Tunm Padidpaccd: <br /> GROUP <br /> ENVIRONMENTAL HEALTH <br /> CONDrrioNALLY ExEMPT SMALL WWft1TtUXNTRAT0R WASTE. <br /> CHE CIC-IN RECEIPT AND C—T4 RTIFICATION STATEMENT <br /> TO BE CCI MEPLE TED BY GE WRATOR. <br /> I certify that the following information is correct,and I have read and understand the requirements fair participation in the Philip <br /> Transportation and Rome4ation Inc.Conditionally Exempt Small Quantity Generator Waste Acceptance Program I further certify that I <br /> am a Conditionally Fxernpt 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 wLeced small.quantity limits or <br /> contain materials not accepted under this programa,I agree to complete a hazardous waste inanifiDst and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAM(),„ viao,-T(m COMPANY ILEI'; <br /> COMPANY AD)MRSS: 101A 17)#: <br /> CITY,STATE,ZW; SIGNXI'URE. <br /> COMPANY PIXIONX: (wq) <br /> vnE. <e/6it to rte. DATE: <br /> TORE COMPLETE D BY PHILIPTRANSPORTA TION&WC4,WDIATION CHECK-IN ATTU'NDANT <br /> GENERAL WASTE T)K9CRn`TI0N HA7ARD AH S= S1 9 OP CONTAINHR WASTE WT( B) DISE COST <br /> CI CUN rL -CODE, L .00UT TYP 'r <br /> L E�M- XSS, TR _t N7L <br /> F-6 MA D <br /> METHOD OF PAYME NT. CASH Q CT-TECK 13 CITFCK NO. TOTALPAID S 1000At) <br /> PHILIP-RANS 8 RL4MrT)CHECK-IN 91'rENDANTS INf CIATS, a <br /> CHECK-IN 1t1S0RTPT <br /> CREDIT CARD= NG nN <br /> 5 <br />