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ID— For affil a use only <br /> ! 1 T C <br /> W � <br /> escrl tion o Hazardous Wastes(continue rom root/ <br /> Hazardous Wastes from Nonspecific Sources.Enter the four-digit number from 40 CFR Part 261,31 for each listed hazardous waste <br /> from nonspecific sources your installation handles.Use additional sheets if necessary, <br /> 1 2 3 4 $ 6 p <br /> Fj Oi OF-5 F 10 4 2 I <br /> I I <br /> 7 $ 9 10 11 12 j <br /> Hazardous Wastes from Specific Sou rcas. Enter the four-digit number from 40 CFR Part 261.32 for each listed hazardous waste from <br /> specific sources your installation handles-Use additional sheets if necessary, <br /> 13 14 15 16 77 18 <br /> I ! ! I I ! I ! !P <br /> 19 20 21 22 23 24 i <br /> 25 26 27 28 29 30 <br /> Commercial Chemical Product Hazardous Wastes.Enter the four-digit number from 40 CFR Part 261,33 for each chemical substance <br /> your installation handles which may be a hazardous waste.Use additional sheets if necessary, <br /> 3f 32 33 34 35 36 <br /> LE � � J 11' 11 _ - T � L ,} <br /> 37 38 39 40 41 42 <br /> tr.. <br /> 43 44 45 46 47 48 <br /> ESI ! <br /> 7, Efsted Infectious Wastes_ Enter the four-digit number from 40 CFR Part 261.34 for each hazardous waste from hospitals,veterinary hos- <br /> pitals,or medical and research laboratories your installation handles,Use additional sheets if necessary. <br /> 49 50 —�–� 51 52 53 54 <br />_.Characteristics of Nonlisted Hazardous Wastes_ (Mark'V in the boxes corresponding to the characteristics of nonlisted hazardous wastes <br /> your installation handles.(See 40 CFR Farts 267.21 —261.24) <br /> ® 1. Ignitable 2. Corrosive El 3.Reactive ❑ 4.Toxic <br /> e' <br /> (oo7) (DO02) (DO03) (Novo) <br /> 0. Certification <br /> I certify under penalty of law that f have personally examined and am familiar with the information submitted in <br /> this and all attached documents, and that based on my inquiry of those individuals immediately responsible for <br /> obtaining the information,l believe that the submitted information is true, accurate, and complete.I am aware that <br /> there are significant penalties for submitting false information,including the possibilit y of fine and imprisonment. <br />'signature, Name and Official Title(type or print) Date Signed <br /> CLIFFORD W. LABELLE // / 7 <br /> t� /( PRODUCTION COORDINATOR <br />:PA arm 6700-12(Rev. 11-85) Reverse <br />