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06/01/2012 16:06 209948 25 ACMESAW PAGE 03 <br />9 <br />11655 'W;NITE ROCK ROAD Date of Ev'.m.54-` <br />Time <br />RANCRO CORDOVA, CA 95742 } <br />60(qj6)31)-V9S0 Informed <br />It1,REAY10E9 iimCs Pnrtic:prtod <br />1,�t4n <br />CONDITIONALLY EXEMPT SMALL. QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPTAN"D CERTIFICATION STATEMENT <br />w � ! <br />ce—lify that the following information is cornet, and I have read and unj9 rstand the requirerner,ts fut participation in the Philip <br />Transportation and Ptmediahot= Inc. Co0tionally !Exempt Small Quantity Guleraior Wastc Acteptanee Pro&a-am. '. further ccr6f; that I <br />am a Conditionally Exempt Small Quantity Generator as defined by Federal and California Stale rcgviations, anal this quantity of waste <br />dcos not ucced the specified limits for the type of waste being disposod. If this west° is tater found to exceed small quantify+ Iim is or <br />cantata materiels not accepted under this pro§rarw, l agree to complete it hazardous waste manifest and comply with other state regulations <br />aS appropriate <br />COMPANY NA,MX: <br />C#T1, STATE, ZIP: <br />COMPANY P110101: <br />NU i'HOD OF PAYMENT'; <br />SIGNATUR : y <br />,.rr . <br />PRILIP TKANS & REMED rtfl"CX-TN A TENDA"NTs INITIALS +„;,,, <br />DATE; <br />.R" KcV%M CHEC'K1:1+: RECEIPT <br />