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TRUCKED NON-HAZARDOUS WASTE DISPOSAL PERMIT <br /> Terms and Conditions <br /> EEMUD APPLICANT INFORMA'T`ION <br /> APPLICANT BUSINESS NAME PERMIT NUMBER <br /> Ce ., r L4 LL <br /> APPLICAN A[LING ADDRESS <br /> /Z�/;7,0 <br /> STREET ADDAYSS <br /> 7 <br /> CITY ZIr CODE <br /> PERSON TO BE CONTACTED REGARDING THIS APPLICATION <br /> &I I_ /—, k x_ <�f-Je4elf- <br /> NAME TITLE <br /> CZEe,- 7z7- ,.7,7 7e-> �-2 i ) 7z_7-_V77_ ��_:�i�L-��^o l• �'��N <br /> PHONE NvmeeR FAX NUMBER ELECTRONIC MAIL(E-MAIL) <br /> EMEROENCY CONTACT <br /> NAME <br /> �&' ) 7Z 7- j'77�> �G�t-) 7 7 - � 77U <br /> DAY PHONE NUMBER NICIIT PHONr,NUMBER CELLULAR I'HOhT NUMBER <br /> (Zal-1 -7z7 - j77-3 <Zoi) %1.3 - <br /> FAX Nt,1MBUt PACER NUMBER <br /> CERTIFICAMN <br /> I understand that I am legally responsible for the disposal of trucked non-hazardous waste and for complying with the Terns and <br /> Conditions of this Thicked Non-Hazardous Waste Disposal Permit(Permit), and hereby certify that hazardous waste as defined in <br /> Section 25117 of the California Health and Safety Code shall not be disposed. i understand that disposal of trucked non-hazardous <br /> waste, as described in this Permit, is subject to EBMUD Wastewater Operations Division conditions. <br /> I certify under penalty of law that this document and all attachments were prepared tinder my direction or supervision in <br /> accordance with a system designed to assure that qualified personnel properly gather and evaluate the infoi7nation subinitted. <br /> Based on my inquiry of the person or persons who manage the system, or those persons directly responsible fur gathering <br /> information, the information submitted Is, to the best of my knowledge and belief, true, accurate, and complete. i am aware that <br /> there are significant penalties for submitting false information, Including the possibility of f ne and imprisonment for knowing <br /> violations. <br /> NAME TIYLG <br /> SIGNAT DATE <br /> (TO BE SIGNED BY CHIEF EXECUTAIFICEF,OR DULY AUTHOIUZED R.LMESENYATIvE. SEE CCRTiftCATION RT:pUIRLMEN'TS ON REVERSE) <br /> Rcriscd 8/29/01 <br /> 20018 '11-1 3MMS 41K93 TZ90 LSZ OTS ttd ZZ:TT Q3A ZO/CO/LO <br />