Laserfiche WebLink
Certification <br />I hereby certh? that (1) all information submitted on this form and on supplemental materials is complete and accurate to the best of my knowledge and <br />ability to determine; (2) the information provided herein, including any supplemental information, such as laboratory analytical, MSDS, etc., accurately <br />describes the waste stream to be delivered to the facility and that all known or suspected hazards have been disclosed. I understand that, once the waste <br />stream is approved by Destination Facility based on this information, any deviation in the source, composition, constituents or characteristics of the <br />waste stream from the information described herein, may render the waste stream unacceptable for disposal, at the sole discretion of Destination Facility. <br />I further understand that any deviation from the information contained herein will require immediate notification to the Destination Facility and <br />cessation of disposaL <br />Name RACHEL LOPEZ <br />Signature <br />Raelidee0/beZ <br />Rachel Lopez <br />Company Name PATRIOT ENVIRONMENTAL <br />Title TSR <br />Date 12 /1/2021 <br />Current Approval <br />Status approved <br />Approval Number PHLF-21-1071 <br />Approved By Darren Hansen <br />Approved On 12/02/21 12:00 am PST <br />Expires On 12/02/22 12:00 am PST <br />Approved Volume 20 cubic yards <br />Approved Disposal Methods NHOO2 <br />Conditions Approved for ADC <br />Page 6 of 6 <br />ID: 0a5856b5-1dcb-4d3c-8907-7ecfebl4baee% Generated on: 12/2/2021