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27.09.2010 21: 45 PAGE. 11 2 <br /> M 393 WEST CHANNEL ROAD <br /> $Ebate of livant. ^7 h Orr <br /> NICfA�CA 44510 Time V <br /> WM.dNVWTAL SEIMICES (877)74R-3040 Unformed W'1 <br /> GROUP Tunes Participated; <br /> �0.Y+eea Ite�+pp ••••• <br /> CONDITIONALLY EXEIMPT SMALL QUANTITY GENERATOR W <br /> CHECK-IN jtECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> l certify that the following information is correct,and I havo maid and understand the requirements forpeuticipatioa in the Pbilip <br /> ��ansportadon and Rernediatiotz inc.Conditionally Exempt Srnatl Q=ty gator We <br /> Acceptance Program. P farther mortify that 1 <br /> am a Conditionally Exenvt Stmsai Quantity Generator as defined by Federal and California State regulations,and thus quantity of waste <br /> does not exceed the specified ilmits for the type of waste being disposed If this waste is later found to exceed euraU quantity lirr�ip or <br /> contain met"W$not Wr-epwd under this program,I agree to complete s hazardous waste manifest and <br /> as appropriate, comply with other state rogulations <br /> COMPANY NAM; � <br /> -•--y. COMPANY REP: <br /> COMPANY A.aDIkESS: L EPA IiDtl: <br /> Cn"x,8TA?E,ZIP: LO p I SIGNATfA <br /> COWANYrHONE: P00 , Q 2 <br /> TITLE: <br /> AATE: -1 7 t <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & RENIEDIATION CHECK-IN�iTTEND�1�t'T <br /> GEN};RAL WASTE DHSCRFPTION HAZ,A 1}i 3PATLT S! #OF <br /> eGriE LCO IZE Ak40U.VT W'P B) DISP. COST <br /> COVE L O DONT 5R WA9T5 <br /> T= NUH <br /> 12- ygt <br /> T <br /> XETHOD OF PAYMENT: CASH Q CHECK U CHECK NO. AL PAID S <br /> PNUIPTR4NS&R. 13D CHECK-IN ArrE.NDAN-rS INIT ALS DATE <br /> CHECK-IN REUPT <br />