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a1°'u 11855 WHITE ROCK ROAD �� Date ofHvent <br />RANCHO CORI?OVA, CA 95742 Time. <br />€91ti} 351•t}9BQ Intbrjnedc <br />t?I <br />WIN )N S+t)"sly7' P SERVICfis <br />GROUP <br />Vrnea Parateipated: <br />�aemReg4� . <br />CONDITIONALLY EXEMPT SMALL QUANTITY -GENERATOR WAS <br />CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br />- — TO BE COMPLETED BY GENERATOR: <br />I certify that the following iltforttiatian is correct, and I have read and understand the requirements for participation in the Philip <br />Transportation and Remediation lne. Conditionally Exempt Small (quantity (3eneraior 1'4laste Acceptance Program. i further certi�'y that I <br />am a Conditionally ExemptSmelt Quantity Generator -as defined �y Federal ane 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 proVarn,1 agree to complete a hazardous waste manifest and comply with other state regulations <br />as appropriate. <br />COMPANY NAME: <br />COMPA.NYADDA938. <br />CITY, STATE, ZIP: tytn <br />COMPANY PRONE: <br />TO BE COMPLETED <br />COMPANY REP; Lu t 0 r' `4 <br />iA.�`i� . EPA ID#;t: <br />'1 SIGNATURE. <br />F Q TiTLS: 54 i'r tL DATE: i�fF Zdt Z <br />TWSPORTATION '& <br />ETHODOFPAYMNT: CASH ® CFECK�d C14ECKNO.i7� <br />113P TRANS & REMED CHSCK. N ATTENDANTS INITIALS <br />t <br />`�� aEv oan i <br />TOTA%PAID $_ <br />CUM IN RECrIPT <br />&a <br />v <br />2 <br />