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Transportation Services <br /> (805)322-4408 <br /> NON-HAZARDOUS WASTE DATA FORM <br /> NAME LAli 4 lam` <br /> J EPA <br /> }_ LD. <br /> ADDRESS l 4 U . moi.., e ' NO. <br /> CITY.STATE,ZIP 'F" j' Fa ; } ' PHONE NO. Ifcc u 1 <br /> CONTAINERS: No. VOLUME. WEIGHT <br /> 0 - TANK _ <br /> QTYPE: 0 TRUCK D RUCK ❑DRUMS 0 CARTONS ❑ OTHER y �` <br /> W - <br /> Z <br /> WASTE DESCRIPTION GENERATING PROCESS t"J Cx <br /> m COMPONENTS OF WASTE PPM % COMPONENTS OF WASTE PPM <br /> W j <br /> J _ <br /> 2 s i C <br /> O <br /> V <br /> W 3. 7, <br /> In <br /> O 4 e. <br /> PROPERTIES: pR ❑ SOLID D LIOUID O SLUDGE ❑SLURRY ❑ OTHER <br /> HANDLING INSTRUCTIONS•. ,t <br /> THE GENERATOR CERTIFIES THAT x'x ,. J tel,. _ •)-r i <br /> THE WASTE AS DESCRIBED IS 100% 10-- <br /> NON-HAZARDOUS. <br /> TYPED OR PAIN RAW&SIGNATURE DATE <br /> NAME J �(+.�. i= ✓F r - <br /> a NO.1 1 ( I I I f t 1 <br /> W r <br /> ~ ADDRESS <br /> LC ° SERVICE ORDER NO. <br /> IL <br /> �. <br /> Z CITY.STATE,ZIP -+' #f4 f ' )' PICK UP DATE 1� <br /> r <br /> F PHONE NO- <br /> TRUCK.UNIT,I D.NO. 7_5 TYPED OR PRINTED FULL NAME R SIGNATURE DATE <br /> R / ?` EPA 1+ t <br /> NAME f f: <br /> J- <br /> NAME <br /> DISPOSAL METHOD <br /> ADDRESS 0 LANDFILL ❑OTHER <br /> J <br /> CITY.STATE.ZIP <br /> U <br /> � <br /> PHONE NO_ <br /> A <br /> TYPED OR PRINTED FULL NAME 6 SIGNATURE DATE <br /> GEN OLD/NEW L A TONS <br /> TRANS S 0 <br /> T C/O pTO MW°FNONE DISCREPANCY <br /> k�•7-l6 <br />