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Y 395 WEST CHANNEL ROAD <br />BENICIA, CA 94510 <br />AGNMEWALSBRVIMS (877) 74$-3040 <br />Et�t4 <br />-- -- — GRQUF <br />Date of Event: <br />Time: <br />Infonned: <br />Times Participated: <br />CONDITIONALLY <br />jjbkgj.j #A <br />I 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 />coIPA vY >\AMI::��i r r j cit COMPANYREP: <br />--�- - vr+ <br />CoiPANYAnDxEss: �, Ii EPA >n#: Cd�ti <br />CITY, STATE, ZIP; C:�`4 zliz�la— SIGitiATEJRE: <br />A HONE: <br />COMPANY N Y P (&A) CnC% = q TITLE: ��, �r 5►�.A Mata DATE: <br />TO BE COMPLETED BY PHILIPTRANSPORTATION &REMEDiATION C CK -IN ATTENDANT <br />5 <br />METHOD OF PAYMENT: <br />M <br />CASH U CHECK e CHECK NO. <br />PHILIP TRANS & REMED CHECK-IN ATTENDANTS INITIALS <br /># OF <br />TOTAL PAID $ X34 <br />DATE— <br />Ll <br />MAO', <br />Ps AO', kEv 410110 CHECK-IN RECEIPT <br />