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El RECORD <br /> 1S - <br /> • <br /> T <br /> T iRtt Ifiv A ' <br /> pMMMZR OF WASTE (M»t be filled b#-producerAsp <br /> gIil1ULER I'BASTE (Must be filled by bauler) <br /> �. .AIT+r!1:. .. <br /> asa <br /> s x D(telnase AdGress:ei- <br /> irttabe dust ity <br /> ' .. <br /> "at A A"n" treat Tim! <br /> ® }� <br /> tY Tel4phont Nushar: .,r <br /> Telephone 11v,Deze P.O. or Contract Ha,• stat <br /> ®aux /_ �]. SCale,Liquid Wat(,ts Na•.lcr't Pt a:strattar u <br /> l�sCtel <br /> order !laced D7: _ ter' _ ' a t Vni'. !:c. <br /> TPpe of Pro tea• " r .� },e <br /> which Produced ltastoe: + � peg. r <br /> oil drtl _ng -CudC Mo. vEhicla.x �vacuua _•.: <br /> Ezaap ex meta plat xE,"egwipweht-'el <br /> wastewater treatssent, pickling beth, pettolean refiniG�) nii. descrlb" waste :as reale.' <br /> DESCRIPTION OF BASTE (Must be filled by producer) 1 r•eztify ear rf ie —4 <br /> • <br /> e <br /> of per, <br /> Check t7pe of wasted; t Cryo e::� + t sties 8e_Q Tmtk "otter asdizent and correct. q-a`sre a. a th.or; ' _ <br /> wAS s: <br /> �. 6.s AI1.Ea':a' i,:.;t �'` r.a a a•h t'" y} <br /> � <br /> Sea:fS l� mast s„ <br /> sIo am <br /> , N <br /> �.aOq,f tae _' <br /> Pada E. <br /> 12. 0 %aemarp vaatd.. {pri.t er :5:e)x _z .c. <br /> �. Soiwc t - ♦. <br /> 6 0 Yetrset,:yt lead sludge 13. Via: vaste <br /> ?. L► f acd •-at-r .e _ <br /> Chev: al to'-et wastes 2&• .� $ _ QC <br /> 15. Q w � ,: e de 1ve swsl,tAe , s;3 :..ffi_ _ y a <br /> Site ti <br /> nd <br /> . <br /> $ €'n. - __ flees:.ta S_.._s <br /> 'affp se adn.'ACCt goo: RWQtg rrq: ". <br /> ( f7) r �`a Health :sem la�lora, `t . 3 <br /> dxi::. auLa: r4SLt S.:ti Jl4i. <br /> MoMs <br /> ' -ey-" :: - - <br /> C puntsstet _"-'�^tsaaion: <br /> Phenolics. solvents (;ist astais (list), € <br /> orgaries (list), cf®a: ) r cover* <br /> s iiy': t>si -ati�,{ zeet+r4.tacio*:� oda No. <br /> trap <br /> t <br /> 2 ......w > disposal (spe:ifpi: pend {__spt,sndi a : <br /> 3 If <br /> waste is aor le <br /> oil Data-.' <br /> ate:f . <br /> LJ <br /> 5 I certify; (or dsclarea acd-rz i�:' <br /> pf per)ur} that t e <br /> 6. and cc. <br /> rdous psopeztiaa f isatc: !I► #._.:d to t�® <br /> tmr/t fll+l® eon ezpleeite �. -,. z„_, <br /> The site operator strait a+.uk. s r <br /> crus O <br /> Cartels ocher gist* Department of Fealth Mite► mOnthl;f fee repdrta. <br /> rpt.. <br /> Containers; other <br /> Ocattoas, b# ! <br /> u_ psotid nliquid pal ago L-j other ' <br /> Physical Etaur 77p.cir7! <br /> E�etial >Faadliaj tostzvctims (if any)+ <br /> . F <br /> „.., . . <br /> Mute is do"VjUmd to tete beat of my ability and it was delivered to <br /> C �.li�ttd <br /> to hauler (if app! 4IQt e1. ED i . g :.'-GS OR SCI <br /> MM !.R <br /> ltmrftiY�Eor deciar+t uad{ir pohiity '��'' 11ATEA IA <br /> of perjury that the foregoinq is tsve ,. -w '�. wave ..._._.�� <br />