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RECEIVED BY SJCEHD (EF) ON 2/3/2020 Profile No. Expiration Date LIQUID WASTE APPLICATION, YOLO COUNTY CENTRAL LANDFILL Instructions: Complete this form and attach analytical and FAX to(530)666-8853 or email to john.borrego9yolocoun .org or ma .'ones olocount .or g or jeff.kiefferkyolocounty.org Questions,please contact 530-666-8726 WASTE INFORMATION Waste Type(Circle one) 1)LIQUID 2)SLUDGE 3)OTHER(specify): Non Haz Liquid Wash out? YES® NO❑ Approx.amount: 3,200 Gallons (gallons or tons(circle)) Approx.Solids <10 (%) pH 6-8 What project/activity generated this waste? Pumping out site clarifiers Site Address: 16888 McKinley Ave City: Lathrop Zip:95330 Anticipated First Day of Haul:01.17.2020 Anticipated last day of haul:As needed YES❑ NO® Known or suspected hydrocarbon contaminants? If yes,provide analytical YES❑ NO® Known or suspected metals contaminants? If yes,provide analytical YES❑ NO® Known or suspected other contaminants? If yes,provide analytical YES® NO❑ Analytical data and/or MSDS provided?Analytical data must be from California State Certified Laboratory YES❑ NO® For Directional boring fluids,Any additives other than Bentonite? List: YES❑ NO® Odor Potential? Describe: TRANSPORTER INFORMATION Company Name&Address: Driver's/Dispatcher Name: Phone#(office,mobile,pager): Vehicle capacity ❑ 1)5000 gal,❑ 2)2000 gal,❑3) 1000 gal,❑Other: WASTE GENERATOR INFORMATION Company Name and Address: Superstore Industries/ 16888 McKinley Ave., Lathrop CA 95330 Project Manager Name Jamie Lima Phone#(office,mobile,pager): 209-814-4432 Address: 16888 McKinley Ave City: Lathrop Zip: 95330 Type of business(note if it is a residence): Grocery division Payment Method: Cash ❑ Check ❑ Credit Card ❑ Landfill Account No.: CERTIFICATION The Waste Generator certifies that this application and any attached information are true and accurate and representative of the subject waste. Waste Generator certifies that he/she has disclosed all relevant information on known or suspected contaminants and understands that there may be additional fees should contaminants be discovered that were not disclosed by Generator. Generator certifies that this waste does not constitute a Hazardous Waste is as defined by State of California under Section 66261.3 of Title 22,Division 4.5,Chapter 11,Article 1 of the California Code of Regulations(22 C.C.R.66261.3). If this application is completed on behalf of Generator,Applicant certifies that he/she has the full authority to bind Generator to these terms and conditions. Applicant agrees to be jointly and severally liable with Generator for all information and representations provided herein. Print: Signature: (Generator or Authorized Representative) Title: Date: ***TO BE COMPLETED BY AUTHORIZED COUNTY PERSONNEL*** WASTE APPROVED?YES❑NO❑ Approved By: Date: Account#: Material: Origin: Grid: FEES: Disposal$ Special Handling$ Wash out YES❑ NO❑ Special Instructions(handling,fees,hauler,etc.,) S:\IWM\Operations\Waste Acceptability\applications and criteria\Forms\old forms\draft Liquid Waste Acceptability Application 2014-2015 v3.doc