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f <br /> s <br /> L3 TRUCKED NON-HAZARDOUS WASTE DISPOSAL PERMIT <br /> ,L=8M D Terms and Conditions <br /> APPLICANT INFORMATION <br /> APPLICANT BUSINESS NAME PERMIT NumBER <br /> ,,,,�""j 9 LL Cl <br /> APPLICAN AILING ADDRESS <br /> 1Z1170 <br />' ST11EEr rIDOREss <br /> zc'��I- <br /> CITY Zip CODE <br /> PERSON TO BE CONTACTED REGARDING TwS APPLICATION NAMJ! Trr1 c <br /> -62K) 727- 8776 130-d7027- 77_7 C�����LO-.O IC (�?v,u <br /> PHONE NUMBER FAX NUMBER ELECTRONIC MAIL(i-MAIL <br /> EMERGENCY CONTACT ' <br /> /�4r1 Ztt <br /> NAME <br /> DAY PHONE NUMBER tN[GHT PnONE NUMBtR CELLULAR YHONL NVMBER <br /> (Z65) 'Z77- !777-3 CZ22) ,3-c6-F;�7 <br /> FAK NUMBER PAGER NUMBER <br /> CERTIFICATION <br /> I understand that I am legally responsible for the disposal of trucked non-hazardous waste and for complying with the Terms and <br /> Conditions of this Trucked Non-Hazardous Waste Disposal Permit(Permit),and hereby certify that hazardous waste as defined in <br /> Section 25117 of the California Health and Safety Code shall not be disposed. I understand that disposal of mucked non-hazardous <br /> waste, as described in this Permit, is subject to EBMUD Wastewater Operations Division conditions. j <br /> 1 certify under penalty of law that this document and all artachrnenis were prepared tinder my direction or supervision in <br /> accordance with a sysrem designed to assure that qualified personnel properly gather and evaluore the information submitted. <br /> Based on my inquiry of the person or persons who manage the,rystem, or those persons dircc•tly responsible for gathering <br /> information, the tnjormation submitted ls, to the best of my knowledge and belief, true, accurate, and complete. I am aware that <br /> there are significant penalties fur submitting false information, including the possibility of fine and imprisonment for knowing <br /> violations. <br /> NAME ` e � � r1'rLe <br /> !/ 1 <br /> IGNATLNE DATE <br /> (T'O BE SIGNro ay CHrEF CXECUOfr10ER OK DULY AUTnO1UZED IkLrKkSeNI'ATIvE. SEE CERTIFICATION RrQUIXEMENTS ON REVERSE) <br /> I' <br /> Revised 8129/Ot <br /> ZOOM 110 3DHaos GaX93 TZ90 LBZ OTS XVzI ZV TT Q3.M ZO/CO/LO <br />