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PSL 40856-.797 P, 2 <br /> 535 GEI I Y COURT,SUITE H Date of EvenC ( I 10� <br /> BENICIA,CA 9451.0 Time: t---'- -- <br /> (N7"!}7aK-3r3+W Intbsa�ed: <br /> nNVERONMINTAL 119[" ev-GROUP Times Participated: <br /> a40M amino <br /> CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br /> CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following infortnation is Correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation Inc.Conditionally ExcWt Small Quantity Generator Waste Acceptance Program. I hirther certify that I <br /> am a Conditionally Exempt Small Quantit--v Generator ay defined by Federml and California State rogulations.and this quantity of waste <br /> does not exceed the specified limits for the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br /> contain materials not accepted raider this program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAMR: ��'�COMPANY xEr: Q Y l <br /> COMPANY ADDR M: c EPA MV! <br /> CITY,STA'171,ZIP: SIGNATURE: <br /> COMPANY PHONE: (. ) '� �(j'� 7 (J TITLE-. DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION& REMEDIATION CHECK-IN ATTENDANT <br /> (JENERAL WASTE DESCRIPTION HAZARD AkeSIATl3 S! N Of CONTAIN WASTE WT(LB) WSP. COST <br /> (ClMICALC ENT Pb ETC CLASS WASTP. CODF. t. CONT tYPUS17.B AMOUNT M <br /> ` ,q n� <br /> METHOD OF PAYMENT: CASH 3 CHECK Q CHECK NO. � TOTAL PAID f <br /> PHILIP TRANS&RRLfF..D CI IBCK-RJ ATTENDANTS EgrnALS DATE <br /> rYe.201 rLEv 1IM6 CHECK-IN RECEIPT <br />