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02/05/2018 MON 13: 09 FAX <br /> 10002/00: <br /> v4Dt r855 l�r•II r): ur)r:;;.r<E,nr+; <br /> m- 1iC•t-rCTC 1r i<nRif iK.)6:C>tif)f.11�!1�(:!l `r;7n� I.)at.:�it(�ti•irt( _. �� — <br /> (91(;)s y 1 U980RECEIVED'lemp.ind- <br /> CONDITIONALLY. 1';?C.A."MJ'-,I.' MALL i-Af'q-fTT�Y� A LTOR WASTE <br /> CHECK-IN Rlr:c'RIPTAND c :R rr t tau :r:rvl <br /> ERMIT/SERV!CFS <br /> - -- <br /> TO (0`, COMPLETED BY Gf:1VrRAT(>R: --- — <br /> 1 Cert(fy/tllal:tbP [t)II<TWI(t( iklf0M.1%tli0u lS UlAlecL,and (.11nvc re.ad7,ud ly d"51--m) thr,rmiu' -cmeats for pu.6C paaou ilt dle <br /> ;lrctcyctc Conditiorrsrlly CICci11pt r"WzjIIQ(murity Uri Cl alOr W-PSTe,At)c;(;ptaucc Yroguam. �fiu7Gret cerci(.y(hat I sm a(;nncliGuuatiy Lxcrrrp( <br /> :ruZtlr QL,ctrltiLy(it:APtaror AS ddirled by I'r.,Cleral and Calili)(-ull Stare legulatio s,and[his ytlautity N waste r(rlr•,;n)tcxceed thcslal:eili(;rI <br /> IuiC; for elle type of%vaa.ce beine,disposed- 1C Illis wasrr. 1°. Wer factud tO excerd tiFrlal_l gtwattiey liatits or rotvala m.orxials nor acrrrNr-rl <br /> rider r s propmn1,Y to complete a hala(do(rs waste srlania';L)resit Coalply with otber,st&Lc remllariouS as 8ppi0pri2te_ <br /> UIVIC'A.NY IYAMr:: �t,-L AO -'1 610 <br /> COMPANY CLEF: j(�( uold� <br /> (7JY1:FltN YAt)t)RESfi: 7--a!/ •1,� <br /> . 57Ly <br /> � � 3 <br /> O1I,pANY 1'�'I1►tE: �� a s - Cl i'�.T t s <br /> of RATE: <br /> TO Tilt; (�O1Vtf.'I',I�T�',Z) 1_iY STX:RICYC:L Cm+:C:K-ZIP M-rENIDANT <br /> Cr-''Trot.WASiF Dr-W-krlM0N HA7.A171) AIi STATE S/ 9OF (�(7NTACNG(: <br /> C:C1 <br /> WetS'[H Wt(181 nry� ST <br /> HY:NIICagt,( STITCJN1�ir Yli.ltCC:, C lAF,:i — WASTEI Com. !. GONIT TXFF_/SfZJi AMOUNT <br /> IZ- <br /> 13 <br /> 3.'ilOD(7.l T'1\Ylt ((': (:t�.SH �i �:T.tk:C'kt <br /> _ 41y' C CK NQ.,t _fUTAL f S e •t <br /> RiCY('f E'CHE(:K.-li. ATI);110Av'L S DATE -- <br /> 17 LGF'V M/t9 � <br /> CHECK rN C,.C:F.IF1- <br />