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<br /> GENERAT ±, �,:, s• w� c, � .�,, r;�t r+>v„ w t=• s^',+
<br /> ,fA o�< Vii'i*1 . :1l x eH`{�Tf"...�tt4�'�t�ly,4,-0- ..tis�,n -,,r+. �' - t, a
<br /> �„ x ty,. �";*;4� t rTTEEACCEPTA n, � �,
<br /> s I"�F'
<br /> sr.. s rt ,eK4Zs !,-„�t�ka f`”:,YYs'1 F,;�. '^F: 75�.:�� N^ r lt�t,�, y F� .�i. •' 7'�
<br /> tY1� hj
<br /> MAILINGA� +ki
<br /> ADDRE S `� ' s 'ws ,,• i .� a�^ ,a r r �5r�a« r.�c.; t w`> - + x, 25
<br /> —ra I,^ 3 � Vii�'}�i�,ti�rR- Y
<br /> " r da t t-a w�' `x.'.'.vf�S:Yt�•',i's,..
<br /> CITY, ST' ,E,ZIP 5 REQUIRED PERSONAL PROTECTIVE€ UIPMENT',e4,
<br /> PHONE -L ❑GLOVES O GOGGLES O RESPS`IRATOR'; O HARD HAT
<br /> -Fl - .,, LI'i
<br /> 5 ❑TY VEK ❑OTHER
<br /> {lam
<br /> CONTACT PERSON
<br /> SPECIAL HANDLING PROCEDURES
<br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE
<br /> ' (�'>C) ,
<br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous
<br /> W_=
<br /> as defined by 40 CFR Pan 261 or title 22 of the California code of regulations has been property y `
<br /> desutbed dawdled and packaged and Is in proper condition for transportation a-cord,ng to applrcaWe 'kill
<br /> regtilatbns AND,It the we=ts b a tnetment tssldus at a prkte
<br /> srlousry mirtrd hourdaus waste
<br /> subject to the Lard Disposal Resinctlors I certify and warrant that the waste has been treated,nRECEIVING FACILITY
<br /> accordance with the recidiarnents of 40 CFR Pan 268 and is no longer a hazardous waste as defined by
<br /> 3'40 CFA Pan 261.
<br /> WASTE TYPE
<br /> O DISPOSAL U SLUDGE
<br /> P CONSTRUCTION O WOOD
<br /> O DEBRIS' LLOfHER ,t+1' .'.`i -t
<br /> U SPE(:ML STI"i°�'!' ?_ yr~` '"
<br /> GEI�EERATING FACILITY 1fi ,1r~;
<br /> * x�� ,i i r« t �tV 11��� � ��� ' � �ak��`'f�'a'•� ,nt�y?�� ;` wr1' _ S.r ' ' " -i
<br /> TRANSPORTER NOTES VEHICLE LICENSE NIJMBEE;y TRUCK NUMBER
<br /> ADDRESS -2 710 gel,/ G60
<br /> CITY,STATE,ZIP
<br /> t
<br /> it
<br /> PHONE END DU BOTTOM DUMP TRANSFER
<br /> ❑ ❑
<br /> i SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-0FF(S) FLAT-BED VAN DRUMS
<br /> ❑ ❑ ❑ ❑
<br /> V
<br /> 1 u
<br /> '
<br /> - CUBIC YARDS
<br /> I hereby certify that the above named material has been
<br /> accepted and to the best of my knowledge the foregoing DISPOSAL METHOD (TO BE COMPLETED BY LANDFILL)
<br /> Is true and accurate.
<br /> DISPOSE OTHER r
<br /> REMARKS O
<br /> SOIL, -
<br /> !,' O CONSTRUCTION xi,�itt``�t y:` >r' r`r
<br /> hDFACILITYTICKET NUMBER' �OEBNRISAf +.l�+t' Yv"r""".t r ixlfa`;r,"r+c:f��",,yti,���,S s°�'4J"`<r,' YW.e�Si+,�^s�`.+,•ii�-^��g-,*_.l'.;�M'S'i;'',yR-�" 1,14
<br /> lei
<br /> -FRIIABLE," .AyESJS7Byy�'g1y�
<br /> !
<br /> 'I',"S• 3{kiMIS.Y r
<br /> SIGNATURE OF AUTHORIZED AGENTil!'r�t,• ,,-- r '%L DATE='.`',
<br /> t 1 Now,
<br /> 9�, r
<br /> xttStC.. x Cld�S' aV.L7,y+7.A�LaL�7>HkMtA�ixss,blrtrc�yidliitutC,:u^u�. ?MlEY '(Ok7RY.'thr.F
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