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ti. <br /> SCJITK w1lRIECORD <br /> lug <br /> PuMUCER OF WASTE (Mast be tilled tiT.producer ItAtfLER Ot WASTE (Must be filled by hauler) <br /> tpetwts et *sND' o .. 44117, <br /> s + 8psinsss ad�resa' treat tt7 <br /> a d�c >: �. <br /> Melt w Adisasa t P - Tim: <br /> :�Y ti <br /> treat 7 lsilpt ne %umbor: _ <br /> Telephone lhabar: P.O. or Contract Hs.• ^ata <br /> 6ata` t/-IL'-7 Stag l,igAd_Watts HW-*111" beg:strati:' <br /> f <br /> .... - <br /> esdax placed Iy.— <br /> AMIN. <br /> Type of Process + tac <br /> rlsich Produced Wastes; el ail drtliYng Cude_9io. Vsticle: wacutt :r_ i <br /> Ezamp e: ante plat sig, egvipsret}t a .r, r c. eFas i <br /> wastewater treatment, pickling bath, petradOM rd"n'69) .' The d ,scrii;A waste was haule' y <br /> rP•+ <br /> DESCRIPfIO?J OF WASTE (*,st be filled by producer) • <br /> re:'ity tcc rf ��.. . -fie <br /> of per ury that the `oreq,,L g xe e <br /> check type of testa*. � .lf <br /> 9, 0 a•>t.t dim-t erred c=rre t <br /> u a su_ .or. a x <br /> 2 .0 2rc a>lut..r. 4. �e1 5�,'" <br /> { $ <br /> V-11.1 <br /> :i <br /> 1 - <br /> • r <br /> a <br /> �. ® PASAL 0'.4911"' t, - • Re_ <br /> 1Z. 0 ,a�ary waste (€r2�t Ox .)Feil Vic. <br /> 5. {� Solvent assts + _ <br /> s'. Q Tetrsettyi tend slmUs 13,_21 Let" site <br /> 7. 0 Ches:::al toilet wastaa 16. --d ase .�CxY . <br /> 15. z. a ge:lva ttd tAe - ti i - a -t'y and <br /> s Thal Calit#Y 3 kwoc9 ra�..a®sar.ts a <br /> x.t ya! _ Ep•-aO� 'vY1i 2i .. <br /> t f7) ® Aepirtsent-'of Health <br /> ceatzx.:t.:oras, <br /> so ft. <br /> C p nitiia] _ -->-.tsa't and <br /> police, solvents (::st), �stals `lilt), <br /> Uppe <br /> t <br /> pbe <br /> zrnarics (list). cyanide) - `-f j 4=-.e�•aet`y <br /> =— _ - .z --.. �_ .�"'� ��..�.. _• � +o - ' x� rat nt-�t>al .tti� ^re .t <br /> � s tf ao <br /> >r �..r L J isposal (spe.ify): Paprsmdijs <br /> 2 El <br /> 3 {' <br /> If waste is held for d'spasal al at <br /> . <br /> Disposal ,zeta: I <br /> I certify (or dscla.re) ani P' <br /> -- El E„1' of pe=)ur) that tre <br /> 6. and co.-rs^y <br /> s: a SA t t S <br /> ymwrdoua properties f Vests: r ..A Tc ..Q to the <br /> t$1..-..a. toxic flsatrsiAle eoetsat�rs....- expletive _ -- - -. _ y ... <br /> pH �"'. r ti rte.+..•r <br /> f e--Z <br /> TAxa alta operator aha:: <br /> c�a <br /> Obs ml* ottaa Slate Department of Health vitn �anthiy fee reports. <br /> .>., <br /> (, taxnera falter, �, Ctrt Ona -_ Qbwother <br /> ial States ®l iquid nslsadC ss other <br /> sap <br /> xa1 lfewdliu8 awtr.ctio s (if aft)t <br /> fto Weoto is do erihed to the hest of oil ability,and it was delivered to y 'Y' ° � OR �l�T <br /> t, icaeaed-liquid waste Ashler (if app2 o). j�m lA' ERIAl.S (0M_!34-"k <br /> 3��, O <br /> ts+t!Ili for declare) ;ander penelt� _ <br /> , of psriury.that the foregoinq is true �, ., ra4e _--__..... ---- <br />