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NO. 697104 <br /> NON-HAZARDOUS WASTE <br /> `TA FORM <br /> 201220 <br /> Generators Nama and Mailing Address Generator's Site Address(it dtfierentthan mailing address) <br /> P.O. FSO.{ 8M&5�3 3202W, KNOMER LjINE <br /> PANDIC) SANTA tAARGAI iTA, CA 026139 <br /> �.�(�C15'1�l`!, C::� i�:?fJ� <br /> Generator's Phone: NQ..:6I.1-.a;r,0l} <br /> Containe0ype removed from site: Container type transported to receiving facility: <br /> I,;,1'brums ❑ Vacuum Truck ❑ Roll-off Truck ❑ Dump Truck ❑ Drums 6 Vacuum Truck ❑ Roll-off Truck ❑ Dump Truck <br /> ❑ Other ❑ Other <br /> EC Quantity Quantity Volume <br /> O <br /> Q <br /> rAEP: ' I:l..l. PL►IGINfx 10 E C C)N 11 Eta <br /> L3J WASTE DESCRIPTION <br /> GENERATING PROCESS <br /> Z COMPONENTS OF WASTE PPMa COMPONENTS OF WASTE PPM 95 <br /> Lij <br /> 1 3. <br /> it <br /> TPH <br /> 2 4. i <br /> Waste Profile PROPERTIES; PH i W i�} ❑ SOLD U L!QUID ❑ SLUDGE ❑ SLURRY ❑ OTHER <br /> HANDLING INSTRUCTIONS: '`!i'�J-R ALI.,AP"r'POPRIA-TE f-EP:Cic--)�1/-.,L PROTECTIVE EGAUMIENT. <br /> i <br /> { <br /> Generator PrintedlTyped Name Signature ` �i`. t ; Month Day Year- <br /> 1_j ji 1 i <br /> i_ r7rtj'l��itz�tt t ri of!Elf Girt behalf of ger�erStoi � F <br /> The Generator certifies that the waste as desrAbed Is 10095 non-hazardous <br /> Transporter 1 Company Name Phoned <br /> BEL.`•51. If2 ?r 13 J 1 <br /> W Transporter 1 Printed/typed Name Signature i Month Day Year <br /> i % 1 f 1I <br /> Transporter Ackndwfadgment of Receipt of Materials <br /> (n Transporter 2 Campany Name Phone* <br /> CC Transporter 2 Printedrlyped Name Signature ,,r' Month Day Year <br /> 1 <br /> Tfanspoder Acknowledgment of Receipt of Matedals <br /> Designated Facility Name and Sile Address Phone# <br /> EMENNO KEPDr'O;•,1;OM.F-TON. CA 902221 <br /> 3i -� 7iCl <br /> l <br /> LIL <br /> C'3 I <br /> Z a�a � f <br /> (J J Printedfryped Name Signature '' f.......-,:t...� _.. Month Pay Year <br /> LU <br /> Designated Facility Ovmer or Operator:Cerlificai$on of receipt of materials covered by this da'a form. :r f j <br /> �, i <br />