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RECEIVED� <br />11855 WTTn Ti ROCK ROAD Dnte of went <br />RANCnOCORDOV&CA 95742 JUL 0 8 2014 nn,o, loUo ? <br />{916} 351-0980 Infnmied: <br />u[vvi2roNail3N f,U. SI VICES Timex Participated: <br />GROUP --•- - - - <br />W�wmReo= ENVIRONMENTAL HEALTH <br />CONDITIONALLY EXEMPTSMQEW WY GENERACOR WASTE <br />CHECK-IN RECEPT AND CLI RTIi+iCNFION STATEMENT <br />TO R E (.OM PI.,E'I i l)13Y GENERATOR: <br />I certify that the fallowing iuf0rmt:tl0r1 is oorrect, and 1 have read and understund the requitements for participation in the Philip <br />Tralispormtion a id'Reinediation lire. Conditionally Excmpt Small Quantity Generator Wastc Acceptance Program I i'uriher certify that 1 <br />ata a Conditionally Exempt Small Quantity Goncrator as defined by federal and California Stale regulations, and This quantity of wasic <br />dors not exceed the specified limits for the type of waste lacing disposed. If this waste is inter found to exectd small qutlnl.ity limits or <br />contain Material.$ not acccptcdunder this program, I ai{ree to complete a liazardcus waste manifi=st find comply.with other state regulations <br />as appropriate. <br />COl+,ikAiNY NAME; <br />COMPANY ADDRESS <br />an S'fA,Ti?, 7lpi <br />CQ14PANYPRONL: <br />COMPANY REP: <br />EPA ID#: <br />SIGNATURE: <br />T11'LE' n A <br />TO BE BY FH IP Z )RAMSPORTATION & REMEDIATION CHECK-IN ATT)D -1 <br />OEIWk.pT, WA.1PR iJP.RC:RIPTION <br />p34' Ph. .RTC;_ <br />ll,4LA.KU <br />CLASS <br />All <br />WASTE <br />'STMT, <br />CODE <br />3/' <br />L <br />H Oi' <br />CO CdT <br />f'MTAINER <br />TYPPJS= <br />WASTE•' <br />AMOUNT - <br />Wl B) <br />D18p. <br />btL'ltl <br />C(m ' <br />Flival exc",?,�; <br />„ _ <br />` <br />IL <br />dl;17 <br />m tr'i`ROD OF PAYMENT: CASH 0 GLIECY' C:1 Wcyl NO. <br />PNII.IP TRANS k REMETU Cl-MC'K-IN ATTENDANTS 1NITIAI S <br />TOTAL PATI) S. <br />DA"I"Ii <br />psc.sm rcevouzi C:T4ff:K-TN RECEIPT <br />c <br />