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395 WES F CH.(,,,fTEL ROAD ', Date Of F1--Tit: <br /> BL-NICI ,CA 94510 '- I 4 „• <br /> Time: <br /> (877)748 3040 WM-Acd: <br /> E1'�'1RONM�N'1'AJ,SER�7rE5 MAY 2 5 2011 <br /> - GROUP Timcs Participated; <br /> 'WrSfem Regign <br /> CONDITIONALLY EXEMPT SNIALL QUANTITY GENERATOR'WASTE <br /> CHE K-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO ]BlE CCOA REQ D BY GENERATOR. <br /> I certify that tbe following information is correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Tub. Conditionally Exempt Small Quantity Generator waste Acceptance Program. I ftirther certify that I <br /> am a Conditionally Exempt Small iantity Generator as dcfincd by Federal and California State regulations, and this quantity of wade <br /> does not exceed the specified limitsfor the type of waste being disposed. If this waste is Iater found to exceed small quantity limits or <br /> contain materials not accepted and this program, i agree to complete a hman <br /> azardous waste ifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NA,.Aft: tJo COIh'd1PANY REP: ���� <br /> COMPANY ADDRESS: �`I(� � C, EPA diD#: <br /> C3TV, STATE,ZFP: <br /> SIG ATUR : %l <br /> COMPANY)PHONIE: (ICj� %� ra - TITLE: <br /> - - — 14 LI DATE. <br /> TO BE COMPLETED BY)PHILIP TRANSPORTATION & REMEDILATION CH.ECIK-.TN ATTENDANT <br /> ENDAN'T � <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE S/ 0 OF CON74INER WASTE !�JT(LB) DISP. COST <br /> CHEMICAL CONSTITUENT Ph. ETC. CLASS WASTE CODE L CONT TYPESIZE AMOUNT <br /> METH <br /> e , <br /> ` I c <br /> s <br /> n <br /> OE IPA.!,'Mt El"T: CEL SH ­ IECK Q CHECK 1110. <br /> ff To 1A 3 <br /> PHILIP TRANS '� R-M'FD CHECK- TA77ENDj NTS Ii,TITIALS <br /> ary io,:o DATE <br /> CRECK-EN RECEIPT <br />