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Aug 18 11 04:54p Harry Singh 209 836 1917 p.3 <br /> �23 <br /> 35 GETTY COUKI;SUITE H Date of Event: <br /> ENICIA,'CA 94510 <br /> Time:Im 877)748-11040 Wormed # <br /> ENVMONUENTAL sEt2V M <br /> GROUP Times Participated' <br /> lLesvm R.q�m, <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR.WASTE <br /> CHE K-IN RECEIPT AND CERTWICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following nforraation is correct,and I havc road and understand the requirements for participation in the Philip <br /> Transportation and Remediation Inc Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I firthercertify that I <br /> am a Conditionally Exempt Small C 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 tiruits or <br /> contain materials not accepted under this program,F agree to complete a hazardous waste rnanifcst and comply with other state regulations <br /> as appropriate. <br /> r C <br /> COMPANY NAAZE l COMPANY REP: &4o-r'! <br /> COMPANY ADDRESS: EPA CD#: <br /> CITY,STATE,ZIP: SIGNATURE: <br /> COMPANY PRONE: �Q TITLE: <br /> DATE: <br /> TO BE COMPLETED BY PPILIP TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> ORNERAL WASTE DESCdUMON I HAZARD AH STATES! #OF CONTAINER WASTE WT(LB) DIST_ COST <br /> CHEMICAL CON jVENT Ph-ETC. CLASS WASTE C01W L CONT I TYPEI Zfi AMOUNT METH <br /> I <br /> i <br /> A <br /> f <br /> 2 <br /> METHOD OF PAYMENT: CAS: CHECK ❑ CHECK NO. TOTAL PAID S �G� <br /> ---rt <br /> PHILIP TRANS&REMED CZECK-IN ATTENDANTS II,%TITIALS DATE <br /> PSC-207 REV 12106 CHECK-IN RECEIPT <br />