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I zuvo UG tl l7Joa/4 rF1U� i�L <br /> NON-14AZA,RDOUS WATER TRANSPORT FORM <br /> GENERATOR CUSTOMER, <br /> Name, . �� rv?. LjName J r .� v r+ '� _ PM r5 <br /> Address "a-3 V Address /07 Se,� �� �`r.�,���f � zz� t5'7 <br /> Phone — L P .2— <br /> Phone _ �l <br /> DESCRIPTION <br /> Description of water. <br /> Volume/Weight l Units- Container(s) <br /> This non-hazardous waste water is montvrJng well purge water, auger rinsate,sampling equipment rutsate,tank <br /> nasate,combination thereof, oras described above Described water mey'eorktain dissolved.hydrocarbons 1 certify <br /> that the above narn4d material has been properly described and classified according to applicable regulations,and <br /> possesses no characteristics that would require its handling as a hazardous waste <br /> Generator/Authorized Agent. _ r pf <br /> r� Print5,gn Date Date <br /> TRANSPORTER <br /> Name Job No. <br /> Address- .r4 _ pick-up Date, <br /> Phone, Z Truck ID: <br /> 0 _ Driver <br /> Sigai Date <br /> DISPOSAL FACILITY <br /> Name: <br /> Address. p Quantity <br /> Units, <br /> Disposal Method. <br /> s R� <br />' Received by '� <br /> 1.� C� <br /> Print 46 4_4� <br /> Sign D <br /> to <br />