Laserfiche WebLink
�j �pylgppp68gAHICE9;INC. S <br /> Oust Code Work Order # <br /> Gen Code Quote# <br /> Caution Notice <br /> High-Hazard Material Form <br /> This form serves as notification that the materials identified below have not been removed from your site. <br /> ment in their current state and require specialized <br /> These materials are not suitable for packaging and ship <br /> handling before they can be safely transported and disposed of. Clean Harbors' Reactive Materials <br /> Group is able to stabilize thele materials for you. A quotation for the stabilization, transportation and <br /> disposal of these materials will be forwarded to you within the next few days. <br /> Container #of Hazard.Key(see below) <br /> Chemical <br /> Size Containers <br /> Ong <br /> SAN JOAQUIN COUNTY <br /> HEALTH Dr=PAI•iTTMENT <br /> . t <br /> Reason(s)materials are being left on site: <br /> 1. Explosive/Shock Sensitive : S. Potentially Reactive/Explosive Mixture <br /> 2.Temperature Sensitive. 6.Forbidden to Transport <br /> 3.Peroxide Former 7.Non-Shippable Cylinder <br /> 4. Potentially Explosive S.Other - <br /> Chemist Notes: <br /> V <br /> o44 14 o <br /> Wattling! The material(s)identified above may be dangerous and may cause serious injury or damage <br /> to property if not handled property. Proper handling requires specially trained personnel and equipment. <br /> Many chemicals become more hazardous with age so prompt disposal, in accordance with all state and <br /> federal regulations, is required. <br /> Clean Harbors recommends that these materials can only be removed by personnel qualified to handle <br /> high hazard material and assumes no liability whatsoever for any actions taken by the customer <br /> inconsistent with this warning. <br /> The following certifies that I am a duly.authorized representative of A it &T,,�'f Ty 0� ��� pi/k <br /> and acknowledge receipt of information for the above listed materials.- <br /> ' C, 11 <br /> Printed Name Signature " Date <br /> Chemist Name 'O CL, f. i% Sales Rep. - <br /> } <br />