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PROFILE NO. q _ O 13 <br /> WEST CONTRA COSTA SANITARY LANDFILL <br /> WASTE DISPOSAL REQUEST/INFORMATION FORM <br /> 1. GENERATING FACILITY NAME/ADDRESS: C h 2 or°^ U•s - A - :e% ` S e., ` <br /> sn -*q ` 055 I3 1 '-; o—i-il Cfe, 5-(rfe- S7o� �. <br /> 2 CONSULTANT (d any) G r o u�,Q t o Tr. <br /> Name: G(zwx L • 14io'4-- c.t.<< Telephone: G-9- 5 - q2-SQ <br /> 3. WASTE NAME: x C u <,4°-� So., 1 S <br /> 4. ANTICIPATED VOLUME: -70LAri 3 DELIVERY PERIOD:_ <br /> (Per day, week, one-time only) <br /> 5. TRANSPORTATION FIRM: r '`l S�" r�4! <br /> 6. TYPE OF TRANSPORT TRUCK 10 CY [Z Semi-end D Double bottoms D <br /> Single bottom D Drop box D Individual ContainersEl <br /> 7. METHOD OF PAYMENT: Check D Cash D Charge � Purchase Order <br /> 0 (Charge & PO must have prior WCCSL Accounting Department approval) <br /> Charge Account Name Purchase Order No. <br /> iJ Bc. 17cteren;-,� C� Chep-� .� wcC 5 L <br /> 8. Description of Process and Circumstances Producing Waste- <br /> c-) ; ( <br /> aste:C) ; ( <br /> For wccSL Use only <br /> ... "s:'-..A Notification: <br /> FORM: ACCEPT: <" " REJECT: <br /> Partial M complete 01 Authorized By: Expiration: <br /> Compatibility: Date: Appointment <br /> Compatible EM <br /> Inoompatible N RATES AND FEES: <br /> Potentially Incompatible go <br /> Disposal Rete: <br /> ND: Yes M No -> <br /> County/State Fees: <br /> Reviewed by: <br /> Date: Other Rates/Fees: <br /> flslwaste.rev 1 of 4 Rev.4190 <br />