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RECEIVED <br /> 395 WES'T CHANNEL ROAD Date of Event: i U � 2-D- ' <br /> BENICIA,CA 94510 )l )_ S 2�>> Timc: <br /> (877)748. 040 Infonncd' <br /> VNMRONMENTAL SERVTCE.STimes Participated' <br /> GROUP ENVIRONMENTAL HEALTH <br /> WC„M„Kms a PERMIT/SERVICES <br /> CONDITIO ALLY EXEMPT SMALL QUANTITY GENERATOR WAS <br /> CHE K-IN RECEIPT AND CERTIFICATION STATEMENT <br /> TO BE COMPLETED BY GENERATOR: <br /> I certify that the following infonnation is correct,and I have read and understand the requirements for participation in the Philip <br /> Transportation and Remediation In .Conditionally Exempt Small Quantity Generator Waste Acceptance Program. I farther certify that i <br /> am a Conditionally Exempt Small tity Generator as defined by Federal and California State regulations, and this quantity of waste <br /> does not exceed the specified limit. for the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br /> contain materials not accepted unde this program,I agree to complete a hazardous waste manifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAME: `� H�S�a�� (� _ VCOMPANY REI': <br /> COMPANY ADDRESS: MAP-TI N L �E� 1 : � <br /> CITY,STATE,ZIP: STOC- ��� SIGNATURE: <br /> COMPANY PHONE: (ZDCt TITLE: DATE: <br /> TO BE COMPLETED BY PHILIP TRANSPORTATION & REMEDIATION CHECK-IN ATTENDANT <br /> GENERAL WASTE DESCRIPTION HAZARD AH STATE Sr #OF CONTAINER WASTE WT(L8) DISK COST <br /> CHEMICAL CONSTJTUENT Ph. ETC. CLASS WASTE CODE L CONT TYPE/SIZE AMOUNT ME <br /> OIL. FII. S 425 2. � <br /> r <br /> r <br /> METHOD OF PAYMENT: C SEI �a CHECK L7 CHECK NO. TOTAL P ID% 5 2 ' <br /> PHILIP TRANS &REMED CHEC., IN ATTENDANTS INITIAL,~ DATE ___ <br /> PSC-207 IMV 10110 C1.4ECK-IN RECEIPT <br /> 2011-06-22 12:39 Paqe 212 <br />