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1975
<br /> 0 , De"Mber . f ! li1 SLENECORD
<br /> srtAtE WATIOR k£six3ac£s ' ` Aoi_ aoARo .
<br /> STATE DfPAk gMENT Of HEALTH
<br /> ER OF WAST (Must be filled by producer HAILER OF WASTE .1!ua filled by bauier)
<br /> PRODUCa Nape.
<br /> IgMe (print or typa)a !.,..s No, Iva
<br /> Ras
<br /> pick up Address: to treat %itp
<br /> creat) tY P
<br /> 7-o �9
<br /> Tejep'one +u k:x.
<br /> Telephone ber:t F.O, nr Contract 1 1, 21sr ��
<br /> Date. — _ Ca txi LS'gs.d �ao:e :�.-` r N--" fIIe3= _
<br /> Order paced 'y 7 1 —_., - -
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<br /> Tia of Pro( � f
<br /> which °.od=:ced l+aa`.es: y a `k
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<br /> tErsr..yle®: ye Ca: p'a'_ nk, equipment Clean ng, u!7
<br /> ww'awarer trentrevt, Pickling bads , petrole= r<ti, �§
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<br /> is true
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<br /> and correct-
<br /> back nacea: d, Tank v;tt
<br /> gU"are ^°
<br /> 2, Rx 0 Oil �I.t�?3�u�8 �i 4
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<br /> FLyais�l vtata: !�aot_i ids:,,; 1 w6go
<br /> Special MMx 1V,1g
<br /> 2�se waste is described to the best of my ability and it was delivere' t
<br /> licensed liquid waste beulor !if apP14A4011. FOR 1NF4)fxag ieX M) TO SPILLS11 1
<br /> certify tdr,declare) under penalty Wgr ' VMAT�I GA { � `�
<br /> f {�riury �neP the f6r aznq is ru+a
<br />
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