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NO. 668857 <br />NON -HAZARDOUS WASTE DATA FORM <br />_[SIT <br />EPA <br />yE�'��:f�,.EiTIN �- <br />N0. <br />NAME <br />p 'VE, 72 i COAST I -'r' OOLIC P a LLC_ ; 011504 el 91 <br />p s'`ti?aiG 70 f sr P £- { 5MG. m _mME— <br />PROFILE — <br />LM <br />PROFILE <br />NO. <br />ADDRES0.BOX "� <br />p�N :H0 SANTA MIAR ARITA, CA 924-5188 STOCK-10� t vK� �c��(�I <br />PHONE NO_ <br />CITY, STATE, ZIP <br />r " <br />CONTAINERS: No. .� �Z,: �+;;'r "� VOLUME a �(; � SIGHT41? <br />TANK DUMP <br />TYPE: ❑ TRUCK ❑ TRUCK ❑ DRUMS ❑ CARTONS ❑ OTHER <br />`lt�' QN C'JAZARDIDU`� (37REA EL GENERATING PROCESS'^`'TE �:tiijlEST!=�A-1, t (EXCAVATION) <br />WASTE DESCRIPTION <br />COMPONENTS OF WASTE PPM COMPONENTS OF WASTE PPM <br />°1'" <br />5 <br />2. 6. <br />3. 7 <br />a_ <br />PROPERTIES: PH ❑ SOLID <br />❑ LIQUID ❑ SLUDGE <br />HANDLING INSTRUCTIONS: 41*—F1'-1&." y 4-'""" �'� +�{'�{ }��} jE; <br />THE GENERATOR CERTIFIES THAT THE <br />WASTE AS DESCRIBED IS 100% <br />NON -HAZARDOUS. <br />DESS A48v'1? <br />a. <br />❑ SLURRY ❑ OTHER <br />TYPED OR PRINTED FULL NAME & SIGNATURE <br />NAME q <br />ADDRESS _ <br />CITY, STATE, ZIP - <br />PHONE NO. <br />LD <br />- t. / I <br />TYPED OR PRINTED FULL NAME & <br />EPA <br />I.D. <br />NO. <br />DISCREPANCY <br />DATE <br />SERVICE ORDER NO, <br />PICKUP DATE { <br />DATE <br />❑ LANDFILL ❑ OTHER <br />L DATE <br />EPA <br />GEN <br />OLDINEW <br />L A <br />I.D. <br />NAME <br />?�i.:t.tt':� .,,a! <br />NO. <br />ADDRESS <br />NONE <br />n c2. ;I"� F S. t �'. k Cis :�`..# <br />s':>: i <br />CITY, STATE, ZIP <br />- <br />PHONE NO. <br />3 Xr; <br />ry <br />TYPED 09 PRINTED FULL NAME & $IGNATUAE <br />t <br />DISCREPANCY <br />DATE <br />SERVICE ORDER NO, <br />PICKUP DATE { <br />DATE <br />❑ LANDFILL ❑ OTHER <br />L DATE <br />GEN <br />OLDINEW <br />L A <br />TONS <br />TRANS <br />S B <br />RT/C <br />HWDF <br />NONE <br />c�Q <br />DISCREPANCY <br />DATE <br />SERVICE ORDER NO, <br />PICKUP DATE { <br />DATE <br />❑ LANDFILL ❑ OTHER <br />L DATE <br />