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395 WESI CHANNEL ROAD Date of Event: f x� 2V 11 <br /> BENICIA,CA 94510 Time: <br /> (877)748- 040 Informed: <br /> ENVIRI]NSjF.N17'At_SERVICES Times Participated: <br /> GROUP <br /> Watt-Reg= <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Inc.Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> am a Conditionally Exempt Small uantity 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 his program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAME: } COMPANY REP: G•erC-C/ O <br /> COMPANY ADDRESS: Q EPA ID#: <br /> CITY,STATE,ZIP: tAow CASIGNATURE: <br /> COMPANY PHONE: (,l 4��Ij .724j TITLE: ���r(� DATE: <br /> TO BE COMPLETED 13Y P 111LIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ #OF CONTAINER WASTE WT(LB) DISP. COST <br /> CHEMICAL CONSTITUENT Ph.,ETC, CLASS WASTE CODE L CONT TYPESIZE AMOUNT METH <br /> r SC-e <br /> ac A 5— <br /> METHOD OF PAYMENT: CA H ZI CHECK ❑ CHECK NO. TAL PAID$ <br /> PHILIP TRANS&REMED CHECK-R4 ATTENDANTS INITIALS DATE <br /> PSC-207 RFV 10/10 CHECK-IN RECEIPT <br />