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19 PR0aIu1I... , <br /> rufifc i <br /> � �QZ�—�f� _ Expiration Date pate <br /> No. <br /> WASTE ACCEPTABILITY APPLICATION, POLO COUNTY CENTRAL LANDFILL, <br /> Instructions: Complete this form and attach analytical and FAX to(530)666-9853 or email to John borreaona yolocounty.atg or <br /> marvJoncs;((-4yolocounty.aEg or icff.kiufTcrRXoIocountv.onz Questions.please contact 530-666-8726 <br /> WASTE INFORMATION <br /> Waste Type(Circle one) 1)CLEAN SOIL 2)CONTAN11NATED SOIL 3)OTHER(specify): ��- <br /> Approx.amount: O (cubic yarxis or tons(circle)) <br /> What pmjcctlactivity generated this waste? "ieldl <br /> Site Address: $�q �" City: 4a1lr0CAL4C-I Zip: 9 S2ct2 <br /> Anticipated First Day of I1au1: -Tuky t'L'fat 9LO2.1 ___ Anticipated lust day of haul: Via®i--��4 <br /> YES❑ NO 8-Iaown or suspected contaminants? if yes,provide analytical,(analytical data application maybe required) <br /> YES❑ NO drown special handling needs? If yes,specify (additional fees may apply) <br /> YES❑ ,NO©''fs material wet? Must be less than 500,10 moisture and no free liquid to be solid waste,otherwise see liquid waste application <br /> YES O❑ Analytical data andfor NISDS provided?Analytical data must be from California State Certified Laboratory <br /> YES❑ NO 2-�Was a permit issued far the project? Permit#and issuing agency: <br /> TRANSPORTER INFORMATION{{ <br /> Company Name&Address: V'a eaos �4 <br /> Driver's/Dispatcher Name: phone#(office,mobile,pager): <br /> Vehicle capacity ❑ 1)Semi-end dump,❑ 2)bottom dump,tEf s)Roll-off or end dump,❑Other <br /> WASTE GENERATOR INFORMATION <br /> CompanyNume and Address: Ora katy- Qrss *rV%S <br /> Project Manager Name Grf%XC.. &ram. ,� Phone#(office,mobile,pager): <br /> Address: a�ck 14. City cv--�t.I Zip: <br /> Type of business(note if it is a residence): C <br /> payment Method: Cash ❑ Check ❑ Credit Card ❑ Landfill Account No.: <br /> CERTWICATION <br /> The Waste Generator certifies that this application and any attached information Are true and accurate and representative of the subject waste. Waste <br /> Generator certifies that heshc has disclosed all relevant infonnation on known or suspected contaminants and understands that then:may be <br /> additional fees should contaminants be discovered that were;not disclosed by Generator. Generator Certifies that this waste floes not constitute a <br /> Hazardous Waste is as defined by State of California under Section 66261.3 ofTitic 22,Division 4.5,Chapter 11,Article I of the California Code of <br /> Regulations(22 C,CK 6626 i.3). If this application is completed on behalf of Generator,Applicant certifies that he/she has the full authority to bind <br /> Generator to these terms and conditions. Applicant agreei to be jointly and severally liable with Generator for all information and representations <br /> provided herein. <br /> Print: :.-4"f%a oL �•r�er� . Signtilure' = . <br /> (Generator or Authorized Repro-sentativc) !! <br /> Tide:, 'etx-- Hate: "i 2 t 4 <br /> *4fr TO HE COMPLETED BY ORIZED COUNTY PERSONNEL#*� <br /> LFEES. <br /> ROVED? YIDS O❑ Approved By; 1 Date: <br /> Account#: material-�10 "'' Origin: Grid: (0 <br /> sal Special Handling S <br /> ctions(handling, fees,hauler,cic.,) <br />