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WASTE INFORMATION <br />Waste Type (Circle one) 1) LIQIJID 2) SLUDGE 3) OTHER (specitY): LIQUID Wash out? YES @I NO 0 <br />Appro,. amount . 10,000 (gallons or tons (circle)) Approx. Solids < 10 triy pH 4 -10 <br />What project/actIvity generated this %taste? SUMP / CLARIFIER CLEANING AT A AUTOMOTIVE SHOP ASSOCIATED <br />WITH SERVICING VEHICLES <br />Site Address 1333 E TURNER ROAD <br /> <br />City LODI, CA 'lip 95240 <br /> <br />thticipatcd First Day of h aul UPON ARRIVAL Anticipated last day of haul SEMI ANNUAL / ANNUAL <br /> <br />YES 0 NO En known or suspected hydrocarbon contaminants? If yes, provide analytical <br />VES 0 NO 0 Known or suspected metals contaminants? If yes, provide analytical <br />YES 0 NO al Known or suspected other contaminants? If yes, provide analytical <br />YES Ni NO 0 Analytical data and'or NISDS provided? Analytical data must be from California State Certified Laboratory <br />YES 0 NO p For Directional boring fluids, Any additives other than Bentonite? List <br />YES 0 NO al Odor Potential? Describe. <br />TRANSPORTER INFORMATION <br />Company Name & Address. ASBURY ENVIRONMENTAL SERVICES <br />Dri% cr'sfDispatcher Na me TEUILA FINAU Phone ti (office, mobile, pager) 707-693-6000 X6040 <br />Vehicle capacity NI I 1 5000 gal, 0 2) 2000 gal, 0 3) 1000 gal, 0 Other: 3000 <br />WASTE GENERATOR INFORMATION <br />Company Name and Address CENTRA VALLEY WASTE SERVICED - CEN644 <br />Project Manager Name SAM READ Phone # (office, mobile, pager) 510-760-2422 <br />Address: 1333 E TURNER ROAD Ci L DI, CA ty: zip. 95240 <br />Type of business (note if it is a residence)! RECYCLING CENTER <br />Payment Method: 03611 Check 0 Credit Card 0 Landfill Account No • <br />CERTIFICATION <br />The Waste Generator certifies that this application and any attached information are true and accurate and representative of the subject waste W ask: <br />Generator certifies that heishe has disclosed all relevant information on known or suspected contaminants and understands that there may be <br />additional fees should contaminants be discovered that were not disclosed by Generator Generator certifies that this v.aste does not constitute a <br />Hazardous Waste is as defined by State of California under Section 66261.3 of Title 22, Di'. ision 4 5, Chapter II, Article 1 of the Caliiiimia Code of <br />Regulations (22 C.C.R. 66261.3). If this application is completed on behalf of Generator, Applicant certifies that heshe has the full authority to bind <br />Generator to these temis and conditions. Applicant agrees to be jointly and severally liable with Generator for all information and representations <br />provided herein. <br />Prim. Joanna Hernandez <br />(Generator or Authorized Representative) <br />Title. Agent for Generator _ Date( <br /> <br />Instructions: Complete this form and attach analytical and FAX to (530) 666-8853 or email to iohn.berrego(iroiolocounty.ora or <br />man.iones dtvolocountv.org or jeffkieffer tliVOlocountv.orv Questions, please contact 530-666-8726 <br />Pmnic No ey.40/61,$),0p -50 3 <br />Expiration Date Jj2 / 1i/9 3 <br />LIQUID WASTE APPLICATION, YOLO COUNTY CENTRAL LANDFILL <br />*** TO BE COMPLETED BY AUTHORIZED COUNTY PERSONNEL *** <br />WASTE APPROVED? YES 11K4c0 Approved By: 1. <br />Account #: 9,- Material 2‘,/ ngin <br />FEES: Disposal S Special Handling S <br />Special Instructions (handling, fees, hauler, etc.,) <br /> <br /> Dale 1, a /ill <br /> <br />Grid_ <br />Wash out yrs gKo 0 <br /> <br />S Its NI Operations Waste Acceptabilitylapplications and crnetiaWorms forms‘draft Liquid Vt aste Acceptability Application 2014,2015 doe