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P Q4 <br /> JAL-28-1998 ;4y22 ID 'JM. INC <br />' 1Wm, T[YC <br /> Approval No NON-HAZARDOUS WATER TRANSPORT TxketNo <br /> s4-8 -8-qb I CERTIFICATE OF DISPOSAL 31 R8 <br />' GENERATOR [NFORMATION CUSTOMER INFORMA'T'ION <br /> Name Southland Co radon Nasse rWNC inc <br /> 4ddress 10220 SW Greeny Rd, 47© Address 950 Ames Avenue <br /> City, Sum Zip Portland. OR 97233 Csty, State, zap Nfi1 etas, CA 95035 <br /> Purcb=Ordcr# <br /> ' GENERATOR CER17J~'iCATION OF NON-HAZARDOUS WASTE <br /> Descnpman of Water Excsvanon Dewaterai <br /> NON-HAZARDOUS WASTE WATER MONITQRING WELL.PURGE WATER AND/OR AUGER RINSATE~TANK <br /> RINSATE OR ABOVE DESCRIBED WATER THIS WATER MAY CONTAIN DISSOLVED HYDROCARBONS i <br /> CERTIFY THAT THE BELOW NAMED MATERIAL 1S A LIQUID E)CEMPT FROM RCRA PER 40 CFR 2614(B)(I0) <br /> AND DOES NOT MEET THE CRITERIA OF HAzARDcKJs WASTE AS DE.5CRmm IN 22 CCR ARTICLE 11 OR ANY <br /> anj R APPLICABLE STATE LAW,HAS BEEN PROPERLY DESCRIBED CLASSIFIED AND PACKAGED AND LS <br /> IN PROPER CONDITION FOR TRANSPORTATION ACCORDING TO APPLICABLE REGULAMNS <br /> VA%fl' �W�f4kn,�4 Q� <br /> Si�ature nate <br /> Generator/ Aittharr�Agrat <br /> SITE INFORMATION <br /> Z'2 <br /> IWM Job 4 Sim# Site Addm-ss #of Dnun Gallom <br /> 14117 2725 W Country Club Blvd, Stockton CA 5 00 <br /> 1 <br /> Estanacted Total <br /> TAAN5YORTER INFORMATION DISPOSAL FACILITY INFORMATION <br /> ' Name IWM, inc / uaf {w ,) Name art 1Mnvuaumeatal <br /> Address 950 Ames Avemue Address 675 SeaPort Blvd <br /> Part of Redwood Ca CA 94465 <br /> Mjlp=s, CA 95035 <br /> t PPh®e 654 36d-IUZ4 <br /> Phone 408-942-8955 <br /> ' Truck ID ff <br /> Dever Name Signature 1't S Tti vl <br /> 5ignatur'e <br /> DOC(TRANPRT FRM) <br />