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i <br /> )73 Resource Recovery Program <br /> P.O.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 /> E <br /> L vis Serve, 2) EN(QE 392- nz <br /> PERMIT HOLDER PERMIT NUMBER (To be completed b EBMUD) <br /> 3) O r o wUet and R O w aXkAA) _ 4) O Ca� <br /> Customer Waste Name (Tobecompleted by EBMUD) Waste Type (l:o be completed by EBMUD) <br /> 5 Source of Waste Stream to discharge., <br /> a.Generator/Site Name b.Site Address c.Waste Composition d.Estimated Total Volume <br /> N Z oo UJ 5c k u l� :c ( g qui ) (gallons/per event or on-going) <br /> Owe <br /> e.g. sludge,liquid) <br /> GLaSS Ce�n-�a�ner n ,CN 1A onqz�at+n - <br /> 953fl�1 <br /> 6) Estimated DeliveryDates: NoaeArnit U- 5,200Z — Delivery Frequency: ra-`.�') X-q (j� <br /> Ex:(Apn716-30,2006) Ex:(M,W,F (3)loads/day) <br /> 'n Is the process generating waste subject to Federal Categorical Pretreatment Standards?Yes❑ No M" <br /> If yes,indicate Federal Categorical regulation and if in compliance with requirements? N/A[f Yes® No�. <br /> 8) Describe process generating waste and its known and potential pollutants. <br /> 7(-P,+c-PoA8 C o lle+ c u e-^6— ( .- - ,, ©,1/toCLI v <br /> 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): O tocxvS DI„noi5 -TC� <br /> Permit Holder(ordulyauthorized representative)'s Signature. f � <br /> :� <br /> Print Name&Title 7� i nature Da e <br /> COUNTS: <br /> EBMUD Res a Recove De ision:A rove Re'eated E iration Date: 3 01 O <br /> Signafore: Date: 1 O dT <br /> FOR EACH LOAD,PROVIDE COPY OF THIS FORM TO GUARD KIOSK <br /> Revised 412/04 <br />