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NON-HAZ/,"DOUS SOIL SAMPLE/RINSAv: DATA FORM <br /> GENERATOR r <br /> NAME ,L , c P 40 -2�6 1 <br /> ADDRESS + 1 FAX 7-I <br /> CITY �Q l Ga STATE ZIP J~� <br /> SITE INFORMATION <br /> NAME PHONE <br /> ADDRESS <br /> CITY STATE ZIP <br /> COMPONENTS OF WASTE PPM # PAILS #DRUMS WATER SOIL <br /> 5 GAL 55 GAL <br /> 1 <br /> 2 <br /> 3 <br /> 4 <br /> By signing below, the generator or agent for generator certifies that the above i ,ormation is correct and the <br /> material considered for disposal is NON-HAZARDOUS. <br /> PRINT NAME ��, �`$� e�/�;51GNATURE c DATE / <br /> TRANSPORTER <br /> Precision Sampling Inc. PHONE 415-456-9875 <br /> 47 Louise Street FAX 415-456-9897 <br /> San Rafael, Calif. 94901 <br /> SAMPLING RIG RIG OPERATOR 719�/ <br /> DATE SIGNATURE S <br /> PROCESSING FACILITY <br /> WATER SOIL <br /> Seaport Environmental TPS Technologies <br /> 675 Seaport Blvd. 20 Recycling Lane <br /> Redwood City, CA 94063 Ph: 415-364-8154 Richmond, CA 94801 Ph: 510-235-8778 <br /> RECIPIENTS RECIPIENTS <br /> SIGNATURE SIGNATURE <br /> DATE DATE <br /> This material has not been accepted for disposal by a facility. The quoted prices DATA FORM <br /> are contingent upon acceptance of the waste material by the disposal facility. NUMBER N 0- 00248 <br /> The disposal facility may require additional analytical tests. <br />