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<br /> � ATEWA'"R RErs�t VReti
<br /> STATE DEPARTMENT Of, H€Ai TH
<br /> OF WASTE (Moat be tilled by producer HAliLER OF WASTE (Wst fillod .by haulor)
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<br /> A44 as. • Businees �.Sdress• Citp r®
<br /> pick up treat ty tract
<br /> P.G. or "_ont, P:•,• eleph�sne 3i€'ter:q Pick Upi Tisa: pas
<br /> TelepAane Member: txaegt:>ete,
<br /> No. '.ti
<br /> order Placed BYDate: ,
<br /> �' Qb No.c.
<br /> +t,e of Pf,"Coss ' n�
<br /> which Produced Wsstt3. �. _ . .
<br /> tE:.ez-,ples: meta plat 2g, equipment eiPar� ug, ail Gri111.,e3-- __ No, Y �° ..ie:. .bra ,� 't ':�rYc`s, �.� -
<br /> r::..:»wae r treetaant, pickl,rg bath, �Oetroleess refiniriy) ?ha %zaCflbed waste a.$e I,,x - =-i awe ., c*_ i._.rx>sa.
<br /> n a urivr:rx rF WATr s.�,a" be f�_.: t•, rr�3d,cer% "_ e
<br /> a ari_ a apt t3
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<br /> C•f Perjury that _ : true
<br /> tank guttae aevi�z:',- and correct. °"`
<br /> pilon 1 r "U:® A. iia i;t i age i an
<br /> ! Pe•:.icidea iG» Q Drilling �sd )i5aE _fa _ ..l<it Yrs
<br /> s, `'"a �a?-at e,wd�a_ ±`s, �? GaYntea�ineted' toil ,natal s+n� _-a _
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<br /> -3a Latex waste
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<br /> Ott .`S ebcify) ancf� �+a€ rest.xctac,.iZ..
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<br /> If waste ie i4, foxd_s; A
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<br /> i t.�., >.,.arl d L: t:c..ca balls
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<br /> Phys?cal Siatas ��'id t__;i :_rgludgaottas
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<br /> Special handling 'nstructi, s ''11' ar,v3t
<br /> Tie w to is described to the beat �i my ability and it was delivered 'to
<br /> s licensed liquid waste hauler ofFM INVOMAMW
<br /> AAW
<br /> certify (ordasclare) unci r ponaity CALL1
<br /> of taa!riuzy.rnat the foregoing is :rvis
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