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P.O. Box 256 <br /> WORLD ENVIRONMENTAL west Sacramento, CA y5691 <br /> No. 17542 <br /> r ' <br /> AENERGY,%} ENERGY, INC. Tel- (916) 371-3617 <br /> Fax.- (916) 371-3684 <br /> ANON-HAZARDOUSWASTE DATA FORM = L <br /> NAME <br /> EPA <br /> ' Z ---AC�r7 T a S n ire f n <z o. <br /> AD6RESS .0 <br /> CITY,STATE,ZIP r�c�aA) CA PHONE NO. <br /> 1921=+>� c a� <br /> CONTAINERS:No. VOL.UMEJOY <br /> Q ---y-- WEIGHT/TONS <br /> Z DUMP <br /> TYPE: ❑ TANKTRUCK ❑ TRUCK ❑ DRUMS ❑ CARTO'NS [ OTHER F�ollaff/Flash C;Ltbe Ilan <br /> } WASTE DESCRIPTION / 1817 P I I d/P 1pAJ �nQbA&ERATING PROCESS 5 <br /> a <br /> m COMPONENTS OF WASTE PPM% COMPONENTS OF WASTE PPM% <br /> rW <br /> J 1 3. \ <br /> a <br /> 2. 4. <br /> O <br /> v <br /> W VOC-OVA READINGS <br /> F SITE VERIFICATION <br /> PROPERTIES: pH NOLID ❑LIQUID ❑SLUDGE ❑SLURRY ❑OTHER <br /> HANDLING INSTRUCTIONS: <br /> l t`l;ffU� r _S'IRATORY ECAJIF't'E-IT k <br /> THE GENERATOR CERTIFIES THAT THE 1 (/ <br /> WASTE A8 DESCRIBED 18 100% NOW <br /> HAZARDOUS. TYPED OR PRINTED FULL NAME d SIGNATURE DATE <br /> Q E <br /> ADDRESS 320e _` CAPITOL A4JFJ . SERVICE ORDER N0. 0 <br /> CITY STATE,ZIP 'ST PI <br /> IF <br /> Z PHONE No.((`�16)3T1 - h1� S7 t/ .a. ODIC — N <br /> TYPED OR PRINTED FULL NAME d SIGNATURE DATE <br /> TRUCK,UNIT,I.D.NO. L4A'Aj— <br /> {1�J ERA <br /> r NAME NO. <br /> o ADDRESS <br /> SERVICE ORDER NO. u <br /> CIN,STATE,ZIP PICK UP DATE <br /> QPHONE NO. <br /> 4 TYPED OR PRINTED FULL NAME&SIGNATURE DA <br /> f' TRUCK,UNIT,I.D.NO. <br /> EPA <br /> I.D. C <br /> NI� �' t� <br /> psC} 4247� <br /> NW W W. R'(W) LANDFILLDISPOSALMETHOD <br /> ADDRESS 6`Is'6 HAY ROV) <br /> ❑ <br /> V(Vf AV1L I F CA y��l LANDFILL ❑OTHER <br /> J CITU,STATE,ZIP � <br /> Q PHONE No.((70;j) 678-1492 <br /> NTYPED OR PRINTED FULL NAME&SIGNATURE DATE <br /> F. GEN OLD/NEW L A TONS <br /> TRANS S B <br /> C/O RT/CD HWDF NONE <br /> DISCREPANCY <br /> White&Yellow-TSD COPY Pink-GENERATOR COPY Blue-TRANSPORTER COPY I Goldenrod-TRANSPORTER rnpv 11 <br />