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08/21/2012 TUE 16: 0 FPAX <br /> REcEiVEL �942/44a <br /> 11855 A ROCK ROAID AUG 17 2015 Daie of Event. <br /> YAP(Cli©COMOVA,CA 45742 ' f <br /> 623(9 16)35 1-Op80Tho <br /> ENVIRONMENTAL l!formcd: <br /> ItNvrrtot+Ir�1�iT'AL s�uvtt�a <br /> -•••`.friAt1P -- WPAITW r MDADTAACI1Ir e8Psnlcip"6 <br /> �epem ! <br /> CONDITIGNI LLy E EMPT SMALL QUANTITY GENERATOR WARTS <br /> CHEC{-IN RECEIPT AND C'ERTIF'ICATION STATEMENT <br /> TO BE COMPLETED HY GENERATOR; <br /> I eerf4fy that the fallowing Jr krmatiar,i6 correct,mud I hove read and understand the r'equiremer3M for participation in the Philip <br /> Transportation and Remediation Inc.�ondttionaliy EXarnpt Small Quantity Generator Waste Acceptance Program. 11' dr certify that I <br /> Am a+Cotiditiottally$xetnpt SmA)l Quantity Generator as deifned'by FCderal sod California State regulations,and Oia quantity of waste <br /> doe®not cxaced the specified Itmits for the type of waste being disposed. If this waste is later found to exceed small quantity limits or <br /> WM Aiu materials not aomptcd under tine proQram,,I agree to complate a hazardous waste Ix rifest and comply with other state regulations <br /> as appropriate. <br /> COMPANY NAME COMPANY REP; Q( <br /> COMPANYADDRESS; O EPA IDa: C. t a*MlWo <br /> CITY,STATE,ZIP: SIGNATURE: <br /> COMPANY PHONE: _ I D TITLRJ DATE; <br /> TO BE COMPLETED BY PH D1F TRANSPORTATION & REMEDIATION CHECK-I1V�ATTENDAN`I` <br /> G$1ttURA1 WASTP DH3CRIPITONT--flAj'A�—bAH STATE SI b or COWTAMB WASTB Wrp) DISP. CO <br /> �CAIiM1CAL oN5flTU8NT Ph $ W CODE I. CnNT T]+P&91�R AMot1NT B <br /> Tn <br /> F)61- <br /> I <br /> METHOD OF PAYHL,NJ; CASH CHECK 0 CHECK NO,_ TOTAL PAID$ 2z' 0 d <br /> PHILIP TRANS&REMLD CHECX-IN ATENDANTS INITIALS Ognq <br /> PSC-,07 rtgvo�/lJ <br /> CHECK-IN kECLIPT <br /> 00 3A63SAIhN Z907,ZC860Z 6Z:00 STOZ/LZ/80 <br />