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F FF'QM `COSENT I NO WINERY FAX NO. :7079441254 I ,rep. 27 2005 11:51 PM P2 <br /> Resource rtcorgry program <br /> Y.A.Box 24055,MS 742 <br /> pakland,[`�J4(;,73.1055 '" TRUCKED NON-HAZARDOUS WASTE DISPOSAL. P:ERNII'I <br /> (510)2X7-16-12 Rax(510)2$7-047.1 ' 4 <br /> i <br /> Terms and Conditions <br /> Waste AcCe tance A xeenlent Addenda A <br /> Feertify description of the wasgte below is a true and acew^ate representatic)n o the wastestream and aniy chbngi <br /> described waste stream will be disclosed to the EBMM Resource RecoveryI'rogra�m for farther revier <br /> ptability. , <br /> PIh T HOI,DE F'TOMER(Waste 11)): <br /> R (�' . <br /> mit Number: <br /> F 2) Specific F.O.Or job number; <br /> 10 Waste Type: ^ _. <br /> 3 Source of Waste Stream to discharge: Cru be unnpintcd ny irsnsun) <br /> s. Generator/Silt Namc; b. Site Address c.Waste Co <br /> mpositiort d.Estimated Total Volume C�iT� ' (i,e., sludge,liquid,etc.) (gallons/per event or on-going) <br /> r (" „� lc�a t W,tr : 90 A <br /> f zakQ�rd, 04 µ-Ep w� G �� U <br /> 4,K Vda �/ W mit�Dt unvy, gr /x r pyP r <br /> 4 Estimated Delivery Dates. tA)eliVery'Frequency: � <br /> Fs1t;(April 1G-30,2(104) Tlx:(M,W,1~ (3)ioadVdiy) <br /> 5) Is the procecs generating waste subject to Federal Categorical Pretreatment Standards?Yes No <br /> 6) Describe process generating waste and its known and potential pollutants. <br /> e � ro��ll toW" C.��f.� i S G�� m�d Cf+C?�t• t�"f�'F ti9i lar � rl� P .W— <br /> ' GC vV, 4q(c a�tyux <br /> Transporter Information <br /> Transporter Company Name, frock Description Truck or Tanker Tntck or Tank Decal Number <br /> Contact and Phone Number ) <br /> r (Yeah,Model) License Number Tanker I.D. Capacity 70 1W d-amFreted� <br /> " re Fleet Number allons) ER <br /> R°t'D) <br /> 8) pees for Discharge of Tracked Waste <br /> The disposal rate iR based on the waste type indicated on this form and as listed in the fee schedule of Disposal Contract. <br /> EBMLTD reserves the right to revolve a pc-,=t for past due payments. <br /> i' <br /> Permit Holder(or duly authorized representative)'s Signature: <br /> . _;�;�,_ - -71 1 z d <br /> Print Name t na Date <br /> COMMENTS: <br /> EBW7)Resource Recovery Program Decisirm: Approved Rejected[] Expiration Datc: <br /> Signature, .bate: <br /> FOR EAC LOAD, ,PROVIDE COPY OF TKIS FORM TO GUARD KIOSK <br /> ttcviged 4/zl04 <br />