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ca395 WEST C ANTNET ROAD Date of Event: 1 At, --1 <br /> BENICIA,CA 94510 Time: 1 <br /> (977)748-3040Informed: <br /> %�iT 1IT-NV ER,7CES Times Participated: <br /> GROUP ... <br /> W'e5Mn R4M <br /> CONDITION LY EXERT SNIA ,L QUANTITY GENERATOR SYASTE <br /> CBIC —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.C nditionally Exempt Small Quantity Generator Waste Acceptance Program. I further 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 fo the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br /> contain materials not accepted under program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. t <br /> �: ;('F i, ' r j ,� COIiII'Ai�lY REP: ��1 CJ <br /> COMPANY NAME: <br /> COMPANY ADDRESS: (� ' �` �� ,�f(n EPA ID#: <br /> SIGNATikiE:CITY,STATE,SI: <br /> � t <br /> IIIIE: DATE:IE:COMPANYPHONE / I I <br /> TOBECOMPLETED13YPUTILIPTRA SPORTA TION & RE-MEDIATION CHECK-TN ATTENDANT <br /> GENERALWASTE DESCRIPTION AFS STATE Sf #OF CONTAINER WASTE \k-T(L3j DISRCOST 41 <br /> iCHEMICAL CONSTrFUENTPh. ETC. LASS tiVAS'I CODE L CO?VI T)TE'SIZE AMOUNT 11.4ETfi <br /> a <br /> t 's <br /> �` [ 3 N <br /> / �/(.�" r�tE <a 1 jji u <br /> i <br /> --v <br /> rTTF-NDANTS <br /> iMETHOID OP PAYIII NT: CAK Q CHECK:NY`s. a'43TALPAID S <br /> Pa`LLTLLp T R-ANS&REMED CHECK-IINITIALS DATE t�l <br /> PSC-707 RE,lIano CHECK-IN RECEIPT <br />