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} <br /> Resource Recovery Program <br /> P,0.Box 24055,MS 702 <br /> Oakland,CA 94623-1055 TRUCKED NON-HAZARDOUS WASTE DISPOSAL PERMIT <br /> (510)287-1336 Fax(510)287-0621 Terms and Conditions <br /> EBMUD Addendum A <br /> Waste Acceptance Agreement <br /> I certify the description of the waste below is a true and accurate representation of the waste stream and any changes <br /> to the below described waste stream will be disclosed to the EBMUD Resource Recovery Program for further review <br /> of waste acceptability. <br /> �) f nuZ) RN 9F�: 2342 - ot-- <br /> PE MMMT ,H�O�L�DE,_R (TD be complmd h MLM) PERMIT N AMER (To be compioied 7yElIM15D) <br /> 3) fl \� �, c1 1�O _ 4) _B \ <br /> _J_DQESS <br /> Customer Waste Name (To be completed by EBMUD) Waste Type (To be completed by EBMUD) <br /> Source of Waste Stream to discharge. <br /> a.Generator/Site Name b.Site Address c,Waste Composition d.Estimated Total <br /> Volume <br /> ( .g•sludge,liquid) (gallons/Per event or <br /> ) <br /> `'� 953oy <br /> 6) Estimated Delivery Dates: ;Zooq— Vast file- Delivery Frequency: M_F 3 Acca <br /> Ex(April 16-3.0,2006) Ex..(M,W,F(3)loads/da <br /> v <br /> 7) Is the process generating waste subject to Federal Categorical Pretreatment Standards?Yes❑No <br /> If yes,indicate Federal Categorical regulation and if in compliance with requirements? Yes❑ No� <br /> 8) Describe process generating waste and its known and potential pollutants. <br /> l �l 9) Fees for Discharge of Trucked Waste <br /> The disposal rate is based on the waste type indicated on this form and as listed on the EBMUD Schedule of Rates and <br /> Charges. EBMUD reserves the right to revoke a permit for past due payments. -� <br /> 10) P.O.or job number(if needed for billing reference): Owens^lllz hpiS 1 <br /> Permit Holder(or duly authorized represenft_ative)'s Signature- �bL�ku <br /> p y�� <br /> Print Name&Title Sig tore Date <br /> COMMENTS, 1 <br /> EBMUD Resa ce eaove rn Decision: rov RgFccted Ex iration Date: <br /> Si re: -�v trrr�a L �• ❑ <br /> Date: <br /> FOR EACH LOAD,PROVIDE COPY OF THIS FORM TO GUARDKIOSK <br /> Revised 4/'J04 <br />