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DEC 16 2010 8: 25RM HP LASERJET 3200 P• 1 <br /> w 535 GMY COURT,SUITE H - . Date of Bvot:t Fn ja 1 <br /> BEMCIA,CA 94510 lima: - <br /> (IM 748-3040 Informed: <br /> Bl�v1GROUP sEIrVYCYS •Times Participated:. <br /> Womm R.Ow = <br /> COINDMONALLY EXEMPT SMALL QUANTITYGEN101 RATOII <br /> CHECK ill RECEIPT AND f_'MMICAMN STATEMETff <br /> TO BE CflMPLE'TEI)BY GENERATQR f + <br /> f� <br /> I certitythat the nllowing inf onion is aorneet,And I have read and underataad tho requirements for partiapitian iu the <br /> T}aaspartatlon and Remo anon Inc.Canditionatly ExOmPt Small Quantity Gtsaerator%sto Acceptance Progtatis i cec fj,l tiY. <br /> am a condltiogally Exe t small Quantity Generator as dafitted by pederaf and 1CaMT'lia State rtguladoas;and this quantity of waate'� <br /> does not zxc-ced the spoci icd limits for the typo of waste being disposed. If this waste is 16-tor fc►iiadto-excxedismall quantity Unifte w <br /> cantainmatetiala mot aocq oteaunder-this program,i tigtrt;to roalplete a hazardous wi gtetuaaifest W comply?t ith other state reguls6ons <br /> ata�Pl� e• • <br /> 0 eA V�)pap, <br /> C40MBANYADDRESS: 4WNATU2#CITY,STAM ZIP: G 1 1 - <br /> COMPANYPRONE: <br /> TIME; - <br /> 3'O BE CQMp'LEB' P]FIILTP'I Ti ANSPtaTCA-flON&RENIEDIAT10�riC C$EMANATTENDANT ' <br /> GEiVL'#tAL WASTE DESCR7P TON ]tAZARD AI STAT13 31 9 flE caDNt�,fxEtc WASTfi wT(t 13} P. {oST <br /> C Nl[ tJUN'iiTttt rrr . ETC.) CLASS WASTE corn3 r, WNT TYPt?/s1ZE A;LUotrN? <br /> METHOD OF PAYMENT: CASH El CHECK CHECK NO. TOTAL PAID S <br /> PI•IUP TRANS&REMED C K-iN ATTEIDANM INT]1�1LS l r <br /> ARROW SIGN COMPANY 2925 <br /> 195140TH AVE 9044MI211 <br /> OAKLAND,LA ea610 — <br />