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05/03/2013 FRI 11: 37 PAZ I�QO1/001 <br /> RECEIVED <br /> 11835WHI li:_OCKRtOAUDateo!' �Rvent: P <br /> RANCHO RDOVA,CA 45742 JUN 2 2 2 015 7'nto. 47 <br /> (916)351-0t Bo Informed: <br /> INItIIibNMItNTAI,414tMGE8 ENVIRONMENTAL. iinwaratticiMed: <br /> GROUP NCAA r�r1CD�LITAACA�T <br /> CONDITIONALLY EXEMff SMALL QUANTITY GENERATOR WASTE <br /> CUEC -1N RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> 1 certify that the following information is call ut,and I have read and understand the requirements for participation in the Philip <br /> Transporhttion and Remediation Inc.Conditionally Exempt Small Quawity Generator Waste Acceptance Program 1 further certify that 1 <br /> am a Conditionally.Uxempt Sumll Qt amity Gcnemlor as defined by Fetteral and California Squantity tate regitlatioa5,and this of waste <br /> duce not t:xcced the specified limits tion the type of waste being disposed. If this waste is later fottrul to execed small quantity limits or <br /> contain materials Opt accepted under this program,t agree to cimplctc a haxardaas waste manifest and comply with othor state regulations <br /> as appropriate. <br /> COMPANY NAME: ' S - COMPANY RUX: <br /> CObWANY ADDRESS: C' '',s -� EPAM#. <br /> CI'T'Y,ftS•I:t rX,Zv: ,' _ f ' �DC SIGNATURE: <br /> COMPANY PHONi.: ( l� _.�2�.� TITLE: DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION&REMEDIATION CHECK-IN ATTENDANT' <br /> (ILNLRAL WASIV 0R3MIP77()N HARARWD AH STATE St #0E- CON+t'TAIM WASTE W't(Lls) DISI! C()S'r <br /> C1MaCAL(_Y7N51rru0T PtY. %A.15 T-1hWE <br /> • <br /> METHOD OP PAYMENT: CAI H/0- CHECK ❑ CIII3CK NO. TOTAL PATI) <br /> PHLUP TRANS&REMF.l3 CTiFCK-TN A'T-I'T'.NDANTS INT!'iALS DATF <br /> PsCaan aavoa/)t CHECK-IN RECEIPT <br />