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NON-HAZARDOUS WASTE DATA FORM <br /> NAME <br /> ADDRESS — <br /> f i PHONE NO. E ) <br /> CITY,STATE,ZIP <br /> 0 CONTAINERS:No. VOLUME WEIGHT <br /> _ <br /> TANK DUMP <br /> Q <br /> Lo TYPE: ❑ TRUCK TRUCK <br /> ClORUMS El CARTONS ❑ OTHER <br /> Lu <br /> WASTE DESCRIPTION " :: ` GENERATING PROCESS <br /> COMPONENTS 4F WASTE PPM °�b <br /> COMPONENTS OF WASTE PPM % <br /> wul <br /> 5. <br /> H <br /> J 2. B <br /> Q 3 7. <br /> a. <br /> m <br /> 0 PROPERTIES: Ptl E] SOLID 0 LIQUID ❑ SLUDGE [3 SLURRY � OTHER <br /> HANDLING INSTRUCTIONS: <br /> TYPED OR PRINTED FULL NAME&SKWNATURE DATE <br /> NAME <br /> W <br /> SERVICE ORDER NO. <br /> ADDRESS <br /> tA <br /> CITY,STATE,ZIP PICx UP DATE <br /> j PHONE NO. <br /> Iry TYPED OR PRINTED FULL NAME 8 SIGNATURE DATE <br /> TRUCK,UNIT,I.D.NO. <br /> NAME <br /> DISPOSAL.METHOD <br /> LANDFILL ❑ OTHER <br /> ADDRESS <br /> CITY,STATE,ZIP <br /> PHONE NO <br /> TYPED OR PRINTED FULL NAME 6 SIGNATURE DATE <br /> LlGEN OLDINMN E. A TONS <br /> TRANS S B <br /> CI0 RTlCD HWDF NONE DISCREPANCY <br /> GENERATOR'S PRELIMINARY COPY <br />