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05/08/2014 THU 16: 00 Fax RECEIVE� I�oarIOU t <br /> � ,�► <br /> 1185.5 WHPfE ROCK ROAD v 1 b 2014 Datc of Pvenl: <br /> RANO TO CORT)OVA,CA 95742 Time: 40 <br /> c916)351-09140 - ENVIRONMENTAL Informed: <br /> 6NVIR0NMHN'rA1.810tV8la% HEALTH DEPARTMENT 'finresParticipmeltr <br /> GROUP <br /> xrffkmtloa4m <br /> CONDITIONAI.I,X L;XEMPT SINIALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECETI'1'AND CERTIFICATION STATEMk:NT <br /> TO RL COMPLETED BY GENERATOR: <br /> 1 certify that the following information is correct,and 1 have rend and understand the requirements for participation in the Philip <br /> Transportation and Remediation Ino,Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State iegulntions, and this quantity of waste <br /> dues not exceed the specified liutits for the type of waste being disposed. If Us waste is Ldcr Ibund to exceed stuall quantity limits or <br /> contain ntnmrinls nut accepted under this program,I agree to complete a hutardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> n Q . � <br /> COMPANVNAME: � � cl" u� � Un�nt�✓rUMI'ANXRIW! Iq a-,� � t� 'Foyt� <br /> COMPANYADDRESS: �-5 W, Wal;v4af0eAd EPA IM: <br /> CITY,STATE,ZIP: -o—rt-o-- v . j26 SIGNATURE': <br /> COMPANY PHONE: (*Zn j- SJ37f TITLE: r DATE: <br /> TO BE COMI'IJI;TED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> (WNFRAL WASTE DESCRIVI ION HAZARD AN STATE S1 NOF CON'I'AINPR WASTE WT(LU) D1SP. C015'1' <br /> (CHHMICAL CONSTITULNT.PL. ETC.) CLASS WASTP. CODE L CONI' IYPIS/s[ZP AMOUNT META <br /> �l t fs lutz <br /> N <br /> rt�C�55i Zp <br /> METHOD OFPAYIIMENit'. CASH JK CHECK ❑ CIIECKNO. TOTAI.PATD$ '2 20 <br /> PHILIP TItANS&1CL'MUD CIWC1C-IN ATTENDANTS TNITIALS DATE A'" 0e `"/ <br /> 1'91:207 lusvaxm CITFCK:IN ILLCL++IPC <br />