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<br /> GENERATOR WASTEACCEPTANCE'NO,"
<br /> art btr ' E o Y1o' rx
<br /> MAILING ADDRESS
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<br /> CITY, STATE, ZIP oil j ff REQUIRED PERSONAL PROTECTIVE EQUIPMENT
<br /> PHONE ❑GLOVES O GOGGLES Q RESPIRATOR O HARD HAT
<br /> ❑TY-VEK U OTHER
<br /> CONTACT PERSON SPECIAL HANDLING PROCEDURES
<br /> SIGNATURE OF AUTHORIZED AGENT/TITLE DATE
<br /> QFJ 18RATOR S CERTIFICATION I hereby certky that the above named malerral is not a hazardous
<br /> waste u defined by 40 CFR Part 261 or title 22 of the Calriomie code of regulations has been properly
<br /> described daaalhed and packaged and is In proper condition for transportation a-mcling to applicable
<br /> regulations ANS,It the waste is a treatment residue of a previously restricted haurdous waste
<br /> sable,to the Land Disposal Restnctiorts I certify and warrant that the waste has peen treated in RECEIVING FACILITY
<br /> accordance with the requirements o1 40 CFR Part 266 and is no longer a hazardous waste as defined by
<br /> 40 OF
<br /> Part 261
<br /> WASTE TYPE
<br /> 0 DISPOSAL 0 SLUDGE
<br /> U CONSTRUCTION ❑ OOD
<br /> ❑DEBRIS THER
<br /> 0 SPECIAL WASTE
<br /> GENERATING FACILITY 1
<br /> TRANSPORTER NOTES VEHICLE LICENSE NUMBER TRUCK NUMBER
<br /> ADDRESS O -27
<br /> CITY, STATE, ZIP
<br /> PHONE END DUMP BOTTOM DUMP TRANSFER
<br /> ❑ ❑ Ed
<br /> SIGNATURE OF AUTHORIZED AGENT OR DRIVER DATE ROLL-OFF(S) FLAT-BED VAN DRUMS
<br />' CUBIC YARDS
<br /> 1 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
<br /> ❑SOIL
<br />' REMARKS
<br /> ❑CONSTRUCTION
<br /> FACILITY TICKET NUM ER DEBRIS
<br /> _ ❑NON-FRIABLE
<br /> SIGNATURE ASBESTOS
<br /> OFAUTHORI DAGENT DATE x a_
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