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07/1?,'2014 THU 14: 29 FAX 002/002 <br /> 11855WHIT ROCK ROAn tate of Evcnt. / /y <br /> RANCHO CO ZDO)VA,CA 95742 'fine ,; p <br /> (Y16)351-098 blformed: <br /> I NORONMENTAL SERVICES 1'inics Prirticipulcl <br /> GROUP — �� 3yV►N � <br /> aestta,Ica+o, 1417 7VLN W <br /> CONDITTONA LY EXE-WT SMALL QUANTITY GENERATOR WASTE No�d <br /> a/AN3 <br /> CHECI IN RECEIPT AND CERTIFICATION STATEMENTP100 <br /> 7 +nr <br /> TO BE COMPLETED BY GENERATOR: <br /> 51 42=2 <br /> I certify that the following info nnation is correct,and 1 have read and understand the requirements for participation in the u <br /> 'I'muspoitation and Remediation Inc_Conditionally Exempt Small Quantity Generator Waste Acceptance Pmgram, I further certify that i <br /> am a Conditionally Exempt Shall Quaptity Generator as defined by federal and California State regultulons,told this gtmndty of waste <br /> does not exceed the,vpuoiticd limits fob the type of waste being disposed. if this waste is later found it)exceed small quantity limits or <br /> contain materials not accepted under this program, l agree to complete a hazardous waste nnauifest and comply with other slate regulations <br /> as appropriate. c �{ <br /> COMPANY NAME: S4H �Od-� �a'S CONIVANV REP: "Jo <br /> COMPANYADDRESS: EPA Tb*: C� '��g1'7Z <br /> CITY,STATE,ZIP: SIGNATURE: 4 ' -- <br /> COMPANY PLIONE: <br /> GJ � TITLE: ,i��i L l,'y(-� DATE: <br /> 20 - '^ F <br /> TO BE COMPLETED BY P . LTP TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> CA3NHRAJ.WA-SWDESCRIPTION IVZARD AH STATE St Dor CON'IAINFN WASTE WT(LD) I DI`Jlt COSI' <br /> (CHEMICAI,COtNS"O1117ENT,Plk ETC.) WASTE CODE L CONT 11 PN1.5V.H AMOUNT METH <br /> US- UJB a 7 <br /> METHOD OF PAYMENT: CASK U CHECK CHECK NO. �"j�� TOTAL PAID S <br /> PIIII.TI'TRANS REMED(lif!CK-1N f IZ?NL`ANTS TMTIALS % '- ' DATE l L� <br /> rsC.ao7 IWV uar►t Cl-MCK-rN RFCT:IPT <br />