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vat G7/ LvIQ wxtu 11: 14 FAX E001/001 <br /> 11855 WWTE ROCK ROAD Uatc of Evcai: 1 2.q/ 1 <br /> RANCI10 COLWOVA,CA 95742 Time: y <br /> L1foIiricd: <br /> =3(916)351-0980 <br /> -GROUP 5CfkV1r,f,% limes Participated: - <br /> W�rcra Rta�, ECEIVEZ�11 <br /> CONDITIONALLY U,XEMPT SMALL OUAY'1<ITY G=ENERATOR WASTE <br /> ClIECIG-IN RECEIPT AND Cli I(fIFICATION STATEMENT FEB 0 6 2014 <br /> TO SI+; COMPLETED 13Y GENIr'RATOR: ENVItONMENTALL <br /> NT <br /> I certify Haat dio follvwing info=atiou is correct,aid I have react and tinderstuld the requirements for participation in the Philip <br /> Transportation and Remediation Inc.Cotiditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br /> atn a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, and this quantity nrwa'tc <br /> does not exceed the specified limits for the type of wmtc being disposed. If this waste is later found to exceed small quantity liWnits or <br /> Contain materials not accepted under this program, I agree to complete a hazardnui waste rnnnifest and comply with other state regulations <br /> as appropriate. <br /> C;OMPAN'Y NAME: , <br /> c ) (�K%0' 'l � COMPANY 17I01: <br /> C=t)M.l'AIYY ADTfRFss: „3o S - W 1p&,0V► EPA LIW t✓A 1. © 3SD C7 <br /> ZIP: OYI SIGNAXIJ11F: <br /> COMPANY PHQNE: (q� ,) I'I't'C�1.: ��,X1,7. VA:I'1:: /" <br /> G �d <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMED ATION CHECK-IN ATTENDANT <br /> GUNUKAL WASTE DIISCRWftON HAZARD All STATE S! #OF WNTAINL'R WASTA WT(LH) DUP. COST <br /> (CaMICAL CONSTITUENT Fil.,RTC.) CLASS WASTE CODR I. O)NT TYPMIZE AMOUNT MGTII <br /> 3.610 <br /> -1 <br /> __.r _ <br /> --7 rf A <br /> i.i#fltft� +9! i'.t'!.X lip X'i!'Y f; i�n 5si L.rxf��..A t..� %a t:i.••"•-• TILT A r "A rn m f/ <br /> ll�� Ia avu- vawaj. <br /> ')41i.iF'W' viVS iYc iGi;Cvil,ii C:rtfrt K-WPd AI 1 LIVIJAr i ;i've.:r l -'�-_ <br /> """" ...°. �°,.. i�rrr:rrr_rrr rznrr•ru.,° <br />