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EVertSUSTAINASIUTY <br /> 0— Land Dispomil Restictm Noffwafm <br /> A Number CARDOOMM <br /> GeneqpWAddrew 1885 Wad Ift Shad Tra*CA <br /> M 0101 <br /> ftstrUctkos <br /> Column 1:List ft Mmiliest Line wriber or Manifest:Line bm. <br /> Column 2: al UAA Mewdous Wasea Coda Oval aPPly tothis s . <br /> Column&Choomthe qVrqxide traAabilk WOW NmWadmdOr OMM or W <br /> Column 4; S 40 CM MAG).if also enter'Contemingled Sci"or ` "°i I be <br /> 49(e k or 26&45-debris. <br /> Column 5:Erftr the Mw of ft appropriate pwa9wh fta b"Kism APPMrdk t for COW OpfVm IF <br /> Column 6:F -F s}located belaw for the constituents M your waste stearn su to, <br /> Col 7:For F039,D00143043, bt to Reference Nundwa IMW in Appendix 2tnr any Underlying Hazwxlous <br /> Check One <br /> Unde*jMg s <br /> F <br /> -FOOS Debris or Sol <br /> I-109 1 Yes A <br /> 2-100196 D007,0010 yes A <br /> 3-111250 `les Hier TOC Ignitable A <br /> Liquid <br /> 4-t _ Yes WmjhTOC <br /> _ lgnkabb A <br /> 5-ID=1 yes kjn <br /> Charecterisfic <br /> W*00 <br /> Column 5 <br /> A THlS FlEMICTED WASTE REOt)IRES TREATMENT TO THE APPUCABLE STAKWARD.Ttas VASIO must b$"SOW to <br /> C.26&3Z Subpwt D,2B8 40 or <br /> RCRA Section dp prior to land disposaL <br /> Coluavan 5 FOM-IMS Refierence Numbers <br /> Cohemn 7 <br /> I hereby certify that SM k*MrMfiM a1l sesocislied d0owneots is canplele aid secuople tD the bWCE ryy►knowkx*p&W <br /> kvidayndon. <br /> rc -Irk, <br /> .w <br /> printed : , kf /� <br />