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ck� I 'LI� E X
<br /> STATE"6EPARTMFNT OF" HEALT" '
<br /> PRODUCER OF WASTE {Moat be filled by praduIM cer 3#AtBLER Q M'AST$ Iat. be til2ad tiler?
<br /> LA
<br /> ' iwir_ .(#yFtnt.,ar type): VC
<br /> r
<br /> (grist of tyildlrIMM
<br /> - Cada Iro.
<br /> we,
<br /> oIlk �Bttairaaa Abc3seas:
<br /> pick up ,itddrasaa r ,:a e s r:• t City,
<br /> treat � (City)
<br /> Tirse. NPa
<br /> P.O. or Contract No.* Telephone z: ) P" .i _p
<br /> Talaptwrea lhsabasr t'+e a
<br /> order Placed �`y: Deta: �ta'te,Ligaid waste hailer"a hes'btreLlan '� ticaiie):
<br /> juts No.: 14.0; of Lorre o, :r o+ 13n#'_ wa.:
<br /> Tv
<br /> pa of Process
<br /> which Ptaduced 'Jastet: vffics , 4 sfaa,s, , ciS:xr
<br /> Examp as: mets plat gy agwiptaent.cieen ng, ol_,I dti111np1--t',de Aa. ' „Se`,.c# ciivi `-
<br /> wastewater treatment, pickling Math, petroleum refinirgl The $E SC3ibq waste was haul'e-d y ae " . a C1AQ9sa1
<br /> ^w and WAS ac- an*r: ,
<br /> DM,Pi nION OF WASTE (Must be fined by producer)
<br /> of perjury that the fJs ' �:9
<br /> Check tape of wastes: ♦ ra o sc th x
<br /> 1. 0 Acid, solution a. Tank bath sedisce:,i and cu rs�t, A,...a " a , ...
<br /> I. [3 A14.14 re solutic: ° c� Cit d I)16K;:S .:sF WASTE 0s�L
<br /> 3@rS0 Pesi4sideb i0.r; sr�
<br /> 4.
<br /> Paint s. dge` Scrrx iilta@ soil' x �;<` •. . EAt AS A I Ad
<br /> S<. Solvent 13. Q, Cannory vast* a ip*1A3t cr Ly e .tea
<br /> b. Lit+bx, C %b,.wasta `
<br /> retrset a lead sladgs S3
<br /> �....
<br /> 7. VhAsm, a, tai ee sande 14. !: rtod a.:i wa ,sz 5!ea Ad3.aeg
<br /> ,. _
<br /> l5. Brine
<br /> as '�€ aa� e. ;S-St*a arnd�
<br /> The lau3r, sraove dir la.say
<br /> Mother {' c[ # I�r it mas an accent i � �<r. State
<br /> a •' tas?asent cf #ieiff$Is r lati rtffi, acid .>cal rwatrxctieana.
<br /> Phcnoli•�aa solvents tlist�, tr
<br /> ..tt, ttgpax _ fz
<br /> ozear.Ca (list), tvanideir of ary
<br /> 0-1
<br /> j4
<br /> :rst4t sent t spo'ca fy;s
<br /> ptbe�►e ;tt�a� ittalisti #4S' Lath?+4esas pc.
<br /> dtspol la tfIt): v spr ding iard£ill itrarc'on well
<br /> r9 tteat a9ff� _ �. �.
<br /> Li «-j
<br /> 2
<br /> L
<br /> If waste is bt!d for is'-gal 4 styr,��e
<br /> ..,�
<br /> v � .
<br /> 3�"PosaI vat 0.
<br /> ,, � ._.«.�...,.�._-.,..�.,, ,.....,..,,.�..._.�,.._..n..�..� �...,._.; nt3aeY +err ai z
<br /> I certify for ,des' -TO) '
<br /> t. .�.....-
<br /> L.J of perjury that the foregoing >.s tide
<br /> or.! cosze s vz at t re
<br /> saaardsua Properties Waata:
<br /> I cont' ���oarlc €1 _ °ta s �-sir�e�. ekT+IdsiYa"
<br /> € The site operator shah' au It s v°._ �t ckc*s cr lit ;o e>. ttiae'
<br /> ,s al zeas rsaritsIe other State Depart r t of E481�th with sonthly £ee F eports.
<br /> Diu .: t42 galy° s by
<br /> Cha LE:e?eras 4...�.
<br /> 1: r} dtsma L..itsrtoas 'bags ether
<br /> physical $braesolid ?lgicid osl.,dsa other
<br /> egad y
<br /> Spgcial Hooditng Instructions €i.' on0l
<br /> "a waste is described to tha baht of say ability and it was delivered to �
<br /> 2ic"sod liquid waste hauler tit apoli FOR IT'tTMA` ICO M To skmu of �>
<br /> certify for dac2acs,
<br /> ) under penalty PAMABT�. liAtLRIA2a µ
<br /> of ;r rjuz}'.that the foregoin! is i rug
<br />
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