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395 WEST CHANNEL ROAD <br />BENICIA, CA 94510 <br />(877) 748-3040 <br />ENMIkONMENTAL SERVICES <br />GROUP- <br />Rics�crn Region <br />Date of Event: i <br />Time: j <br />Informed: <br />Times Participated. <br />CONDITIONALLY EXEMPT SMALL QUANTITY GENERATOR WASTE <br />CHECK-IN RECEIPT AND CERTIFICATION STATEMENT <br />TO BE COMPLETED BY GENERATOR: <br />1 certify that the following information is correct, and I have read and understand the requirements for participation in the Philip <br />Transportation and Remediation Inc. Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I further certify that I <br />am a Conditionally Exempt Small Quantity Generator as defined by Federal and California State regulations, 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 under this program, I agree to complete a hazardous waste manifest and comply with other state regulations <br />as appropriate. <br />COMPANY NAME: <br />COMPANY ADDRESS: , -e <br />CITY, STATE, ZIP:a <br />COMPANY PHONE: <br />COMPANY REP:Z' <br />EPA tF- <br />EPA ID#: CL 00 , ") Zxf <br />SIGNATURE: f. r <br />TITLE: DATE: (j <br />TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br />GENERAL WASTE DESCRIPTION: HAZARD AH STATE S/ # OF CONTAPIER <br />CHEMICAL CONSTITUENT Ph. ETC. CLASS WASTE CODE L CONT TYPEISIZE <br />WASTE <br />A;VMU`NT <br />W7(LB) <br />I <br />DISP <br />I METH <br />COST <br />i. <br />PSC.207, RL` jJ,;0 CHECK -1V RECEIPT <br />