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iv <br /> hlo <br /> !� Xecv;lia,, ❑ Tel: Ii)Ruad•E:t-t Fix: <br /> 15) C.\9.t;0:.j;Ih <br /> ROMIC Lab l ac•kut; Tel;(�1 1?'_! 16?3•Fax:I41?I 4fi'_-'_il j <br /> Field Services (8001 RUNIC-4-G(800-766-4_48) <br /> ENVIRONMENTAL <br /> TECHNOLOGIES CORP. Cr�iaulli�t•, <br /> ' ❑ ROMiC SOUTHWEST <br /> 61h0`,V.,AIIisoiiRd.•P.U. Box�OOd•Guituller.AZ 3;226-il 10 <br /> Tel:too])796-I OYI)•Fix: 796-6211 <br /> WASTE CHARACTERIZATION FOP\M (300)932-J760(AZ and CAonly) <br /> ! Standard Generic Lab pack Recxcle%re,:::n.•specifications --_-- <br /> Certificate of Disposition requested F orni Code B-I Sample if No sampic PUSH! <br /> `ew customer Existing customer Sales rep: Cost. Serv. rep.: <br /> Quoted ; ---_'— Frei�lu S Profile fee S _ P.O. <br /> Continents: <br /> • • l 4 r <br /> • y Nr <br /> Company ---- Phone <br /> Contact/Title Fax ( > <br /> Site address <br /> ' Manifest/Billiml address _ <br /> EPA ID i Extremeiv Hazardous cermit # Expiration <br /> Company Phone <br /> Contact/Title _ Fax ( _ <br /> Billing address <br /> Trans-porter name EPA ID <br /> Waste name <br /> Specific process generating* waste (check one of the following) <br /> Spent Cleaning Degreasin` Line/equipment flush _ Empty containers Aerosols __ Spill residue <br /> ' Discarded product Off-spec./intermediate product Other <br /> n I t i <br /> 5.�-ballon drums Lab packs _ Bulk�=allons _- Bulk pounds _ Cubic yards <br /> 4eekly 'lonthly Quarterly A;-:nually Onetime Other <br /> .� <br /> 7earl-tify <br /> 1 that all information submitted in this and all attached documents is complete and accurate and that all known <br /> opected hazards have been disclosed. I further certify that any samples submitted in conjunction +with this <br /> ment are representative of the waste to be shipped. <br /> Authorized generator signature <br /> Print name/title Date / J <br /> Attachments ( total paves): MSDS Lab analysis Other <br /> ' CO:ti1PLETE REVERSE SIDE OF FORM 110 (111/93) <br />