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CALIFORNIA ttU �- T NUE £ �. <br /> r 19'x5 <br /> STATEWA 2 R St>(fRCES' 1tO ARD ,`t <br /> rb <br /> STATEDEPARTMENT Of HEAt3+}pRODM <br /> ER OF WASTE 04ust be tilled by producer HAULEP OF WASTE (M--,st be filled by bau29r> <br /> xess (print or type) 'I _!. . <br /> N,ams. 'VC.T,t cr type): � <br /> %M1 tg- <br /> u�i a as e ye circe�o <br /> pick up Addressa AIM4 iV ,- tikbe treec <br /> „-. treat Pick U /-���� Tim <br /> U : Qpre <br /> Telephone Number: P.O. or Contract No..L- Pa ep ^E p' <br /> order Placed Dya <br /> h, , f cvq a aY he,..,�...�. <br /> Type of Fcucaaa a �� <br /> A. <br /> which frodaced <br /> tExasaaptes: aa4 plat ng 'equipse:t claanSrtgs aii r3:tili .-rL,de �« }es �e•.:vi <br /> vastevater treatscr.t, pickling bath, petroleum retiiiiY,g; ?he See ribeci waste yes taa�le3 .'r ar `o r..:e dis+posal <br /> -A,rt , nell^v and vas v---Fteti. <br /> D,. .RT IYNON OF w'ASTY be lle by producer) � t � ri .:cv +- .,7 <br /> 1 i,r _._ _"'.iso.of perjury tka. s. � 2; , eCheck t: pe at easatea gnatune ga,aTana ��at t xs se33 ,#t mhd c Y�tt <br /> 2. �,ipc %a;uticn �� onDJSP)SM _ <br /> 9. fes .ci yea iDa-�a 3r1311tg :m d <br /> ti <br /> 13. [? Coxa Yrtatvd Sail <br /> t >+a Ca^neY waste ,5 rt � T; a <br /> 73 14, <br /> 1 . ' Brine <br /> :..X n...Rx t -�i�ave 'fi Ne b •t.�i L `-' ...si .y .LL <br /> / <br /> �Otha: 01"rit ) s <br /> o � a:= of nces? e a; any local <br /> dat <br /> ,,.w.�........: .,_. • .. �" �tr&�.gaetat..t,epa t�.�re - _ v `".,,� <br /> °x eas ir�..rerati�, itra'.zsa:aa :tact tta „as �•^- a <br /> Ir t <br /> a AS a°e 18 heldl iz:r <br /> i sal <br /> ` at <br /> and ,-or artIke,< <br /> darmg�.�r.s Feop.•*t:e u;*ate ',- <br /> atu e ei -T>� a.t <br /> bit cas8rtsiva emus>uY �. t e <br /> i �.._.... _ ?fie a;' Esera o a a -e,4,'ale w i <br /> barrels othar Mate iae ar a �* a�� �ti aonPkxly fes report*_ <br /> Car.L&!LtZs; , Li <br /> (Nbes n-a_ :a j actosa gage ott.rs <br /> epmcai <br /> pbyairml ".ir'!d slsdgs 0tit*r, <br /> _¢ 3 <br /> Special Ift"4i ret Snstry s i ary3x� Y..m,, w- ,.�and <br /> Tl�* waste is described to the beat of my ability and it was delivered to <br /> i licensed liquid vests ;auier (if appl e>. Snmi*w To SPILLS (M 0= w2w1win MWIM , <br /> I <br /> Z certify (or declare) under penaltyCALL �" <br /> IALB <br /> of a riury-that the or o nq is true <br /> er ,. Faas _. ....,, � <br />