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395 WEST CHANNEL ROAD Date of Evenr <br /> BENICIA,CA 94510 1.0 <br /> (877)749-31140 Timc:Informed. q <br /> E V`.'Trt ON1v1 ENTAI,SERV 1C ES <br /> -- GROUP - Timex Participated! <br /> me+e"Rea— <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IBJ RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following information is correct,and I have read and understand the requirements for parricipation to the Philip <br /> Transportation and Remediation Inc. Conditionally Pxotnpt Small Quantity Generator Wastt:Acceptance Program. 1 further certify that I <br /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and Califomia State regulations. and this quantity of waste <br /> docs not exceed the specified limits for the We of waste being disposed. If this wase is later found to exceed small quantity limits or <br /> contain materials not accepted under this program.I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate, <br /> COMPANY NAME: <br /> fS ICr COMPANY REP: Qom_ <br /> COMP.ANYADDRESS: G -I EPA IDN: C ('D O <br /> CITY,STATE.,ZIP: pC Cn SIGNATURE: <br /> ,C0MPANV PHONE: ? q TITLE: f'4 AM . Ck U JIJ-e�b„�1 <br /> '100 GL n cob <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> tiI.NERAL WASTE DESCRIPTION HAZARD AH STATE, S/ A OF CONTAINER WASTE WT(LD) DISP, I COSI <br /> (:HEMICALC N TMJL•NT Ph, ETC. CLASS WASTE CODE L CONT TYPR ZE AM 'NT METH <br /> 35 , <br /> O <br /> IETHOD OF PAYMENT: CASH M CHECK O CHECK NO / TO AL PAID S v <br /> PI ItLIP TRANS& REMED CHECK-rN ATTENDANTS INITIALS _ 1�--� DATE <br /> CHECK-IN RECEIPT <br />