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.. <br /> L$'5 CALITORNIA LIQUID <br /> STATE WATT-REStlttRRbL"BOARD" <br /> STATE i)Ef AP;M NT OF. HEALTH' � <br /> Eat OF WASTE (Wast be tilled oy;producer HAULER OF WASTE ( t be filled by 11uler) <br /> PRODWa$'sE¢rt %V.Iit:t Or. t;Vit' Code so. <br /> Mase (print or tppe)r mailda yo, <br /> • $uai,c;ie A3a te116: 1 <br /> Pick op Address: . +� j <br /> creat tY Te c r. auae"r.. Pick Up. 2- Xiaa: f <br /> Telephone Nber: P. li <br /> O, at Contract �a. 700�� / �m ata <br /> Bets: ��" Irl. ��I �.,._., -,osn p: t!i p'0tc$ la)� <br /> Oader Plactd Ry: <br /> Type of }'SGCess $ <br /> scbicb Froducad waste" _ -„z �., <br /> tEx�sp2ea: sets plat ng, equipment clean ng, oil c (ling-m c <", V cid: __i a :, =s ?,arre.a <br /> c.tv� <br /> wastewater treat"rt, pickling hath, petroleum refii.ln$t f�,t u'4rcribed �-o.te e'en tea *'Y m ` the d:�ecroga. <br /> !-a ESC -jPT!0q OF WAStMusf be i i 11r d by producer) a <br /> Check type of wastes: 4 <br /> 1, M Awe:° s;ls;tic--= d. )ank b team a i¢er;t and c:.r_e .< ,. a re a t az a <br /> 2. a :s g : �n 4. Gil <br /> 3a Pesticides 141. .,rillibg UP-10, <br /> t)1 P'LS <br /> 4. ?$ Pair.t a_o..g? rated," <br /> 'Al Q dont "rated it and aa�4 � <br /> S. '� Snives.r 12. [3 Cannery was-4 sect "Ptl.nt c .> <br /> �� tra r vl t ai <br /> _ <br /> 44 <br /> 91u440 13s Latex wasrc fry Addy, s <br /> mud, sr. _ s �o <br /> " 19, 0 $r!na err <br /> Otz (Spec i fY} co c, <br /> r .< uk a _ t4;A jcins, and <br /> ral, _ <br /> phenol lcs, <br /> organics (list); ,*rao. <br /> yr <br /> cps •ix r � f T ze as ..y <br /> tbo:z, az it a>tlsi _ <br /> a� x ts�in Ltrgds :. <br /> J <br /> La <br /> r..PCII a a i D e,t <br /> r <br /> n � Y <br /> a a "it w <br /> dazar9uua Ps.�part3�m� "��at�. <br /> _r, 3�A ble fce alae � xn .. a. _,s rho <br /> pet -.s _ .. , ' Pia ai a �r� � _ :z=��.. �°�ss;.� a. i��.1:.° s ..c.�+� _ , <br /> of ; a d to to <br /> kik r :wasLi <br /> le attaA State La arcan,.e :�vf t*11th Witte asrtElly fee raporta , <br /> 41,2 ol <br /> " } <br /> �T.3raaa ) — d: s I msj:a:'.cai is cL e <br /> 34 1f'9 <br /> Ph'ysicsi 3tataz y sac d ,: s,id �sludga otbar77,7....}#... <br /> �:re .�, <br /> spatial Kmnd 'A# lnstru:A.s s <br /> 'life waste is described to the Dealt Lf my ability and it was delivers,0 to <br /> a licensed liquid vest* "auler fif aPPl e). FORi TO SPIUS Oft QMMt MMOCTU UMLYM <br /> ' �ti►�r ilp (sr,declar�a) u r psnai H,1,ZA WA OR MM MAT ULE �, ) <br /> .. <br /> o! p+er'3ury:that the toregairq iserneis � s <br />