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NON-HAZ,` 'DOUS SOIL SAMPLE/RINSF DATA FORM <br /> GENERATOR <br /> NAME Ms. Roberta M. Kaitz PHONE (510)582-1997 <br /> ADDRESS Kaitz Property Services FAX <br /> 20880 Baker Road, Ste 9 <br /> CITY Castro Valley STATE CA ZIP 94546 <br /> SITE INFORMATION <br /> NAME Country Hollow Apartments PHONE (209) 952-2377 <br /> ADDRESS 5858 Morgan Place <br /> CITY Stockton STATE CA ZIP 95219 <br /> COMPONENTS OF WASTE PPM # PAILS # DRUMS WATER SOIL <br /> 5 GAL 55 GAL <br /> 1 Diesel 1. 1 nnp x <br /> 2 Chloroform 0.0053 one <br /> 3 22CCR metals Ba, Co Mo Ni below one x <br /> 4 Se, V, and Zn <br /> By signing below, the generator or agent for generator certifies that the above information is correct and the <br /> material considered for disposal is NON-HAZARDOUS. <br /> PRINT NAME j���i,�. fi�SIGNATURE DATE <br /> TRANSPORTER <br /> Precision Sampling Inc. PHONE 415-456-9875 <br /> 47 Louise Street FAX 415-456-9897 <br /> San Rafael, Calif. 94901 <br /> SAMPLING RIG RIG OPERATOR <br /> DATE SIGNATURE <br /> PROCESSING FACILITY <br /> WATER SOIL <br /> Seaport Environmental TPS Technologies <br /> 675 Seaport Blvd. 20 Recycling Lane <br /> Redwood City, CA 94063 Ph: 415-364-8154 Richmond, CA 94801 Ph: 510-235-8778 <br /> RECIPIENTSRECIPIENTS <br /> SIGNATURE -�C r' SIGNATURE <br /> DATE 22 -- ! DATE <br /> This material has not been accepted for disposal by a facility. The quoted prices DATA FORM <br /> are contingent upon acceptance of the waste material by the disposal facility. NUMBER N 0— 00116 <br /> The disposal facility may require additional analytical tests. <br />