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.05/03/2013 FRI 11: 37 FA� I/Got <br /> REGEIV EL <br /> M3 <br /> 11855 WHIZ-e It,OCK ROAD Date ot,went: <br /> RANCHOc,�1RDOVA,CA 95742 Tuna: !` ' ;r7 <br /> (91 6)351-o�}tto JUN 2 2 2015 traforawd; <br /> t:NVIRONMUNTAL xttnvtM 1 1' <br /> bWS mticipated' <br /> GROUP ENVIRONMENTAF <br /> IC617-(J r)CP5QTtiAC%1T <br /> CONDITIONALLY EXEMPT SMA,TJ.QUANX'H Y G1(;NERA1'OR WASTE <br /> CHEC C4N RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that the following i formaticm ix correct,and I have read and understand the requirements for participation in the Philip <br /> Trunxpmtation and Remediation Inc.Conditionally Exempt 9=11 Quantity Generator Waste A emptance Program- 1 further certify that 1 <br /> am a Conditionally Exempt Sumll Qr antity Gencratar w defined try Federal and Ca]ifornia State regulationt,and this quantity of waste <br /> docs not cxccLd the specified limits for the type of waste being disposed. If this waste is later found to euroed small quantity limits or <br /> contain materials t}ot accepted under this programk l agrcx:it)ctunpicte a hmTdnue wa6o manifest and comply with othor state regulations <br /> as appropriate. <br /> COMPANY NAME: COMt'A NY Iil s: 4� <br /> COMPANY ADDRESS: G - —EPA nW. <br /> CITY,91,A11GIP: % SIGNATURE: C <br /> COMPANY PTIONli.- �' – TITLE: DATE: <br /> TO BE, COMPLETED BY P ILIP TRANSPORTATION&REMEDIATION CHECK-IN ATTENDANT <br /> GtNLRAL WASIV IMCRIP110N INAZARD AH STA1E st ff Or CONTikIIQ[til WAS'M wr(w) VISP (MST1C <br /> IIIWTCALC01461 ' U1{ 1*Ph. Y:. C3 ASS W AMOUNT IvSLTII <br /> LTJ <br /> i <br /> ( .CIC l'CSS�,� ' ( tel ^ <br /> METHOD OF PAYMENT: CAS CIIFCK U CIMCK NO. TOTAL PAin i G> <br /> PHILIP TRANS&REWJ)CNFCK- A'i U NDANTS INTiZALS DATE. 11–,2_-1 <br /> PICa07 aavelti: CHECK-IN RECEIPT <br />