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arkRECORM <br /> z j. <br /> l txBt f1 WASTE (Nast be filled b�'produpe ti `> iAtiLER WASTE (Must <br /> be tilled by hauler) <br /> _ ; e <br /> a-{ t M*"it o dao." , ' <br /> s � �tsinass adc.res�: <br /> flea up t t( tze t Ler Time: <br /> p <br /> treat . Y y' shone Phm4or: '''F <br /> Isle bona lsrbozs P.O. or Contract No.- <br /> to <br /> P <br /> ID <br /> St�e��e L14uiL Waite Ha Icr"c Crg!stratiar l�s;tc <br /> z Plated ST: ,g> .c c Uric He. <br /> s Sob lio.: __. <br /> tis of !toshe <br /> rich P ses vastest <br /> £xamy ss metal plat ogtai 'tjeamzvqk sYl drtli3,ng -Cw �eticla: -e .�- c-:s 3:sylss, e, <br /> r <br /> wastewater treatment ickli hath tr ref" waste r:! h ula y <br /> . P nt. to Thr drscrlLie�! <br /> fs�aI'i:tY dad bP°C,; en?t vr•4 <br /> DESCRIPTI05 OF WASTE (!fust be filled by producer) � ce.«its ter rf '� _le _ e <br /> of per4ury that the wo:eq�ir•g r� e <br /> cheek type of Wastes: R <br /> 'a.i3 rt a,ttoa► sadimerat and CczraGt au_ or <br /> 1. U A:'• s. +Uti oa _ a.. <br /> 2. Aihs:ins xoi+,t:cn - a <br /> �na`uze o. <br /> Pesticides t , <br /> 1L, t2 r - <br /> Pa!'nt'e:od e' ' c <br /> t ry waaee` (print 0 .g;�,: <br /> 5. 13 Sciver t i1, _e c. <br /> Site <br /> Tettaet., a lead sluOt 13. 2� ' rests <br /> 7. Cj Chea::at Wastes 14. and acs '•aCcr <br /> s 15 fl Ps=Wa c �. -: •,g ...;. `y and <br /> r <br /> -. -de,ive rs LJ+e <br /> ' �RwQCB req. <br /> *hae <br /> acceptaolaLpoawl <br /> ia®aer.tsf..a <br /> S. <br /> Part Of Health requla*.iot:s, -c,i rcatz;.c:one, <br /> phenolics. solvts (test., metals {list). pvm <br /> -rRarics (list), Cyanide) ,- Y-cove" <br /> est ( moi Y ss: �,trst.Eact�,fi :t: eetscior,- ate so, <br /> e f }: _ <br /> 2 A �, <br /> disposal (specifpi' 9cn3 •,pras�3iI� ;a .19-1—1_ a. <br /> �s..*. ° <br /> - - rt <br /> * If waste is bald for 41 set = <br /> *. — <br /> • Diihosil meat <br /> ❑ I certify. (or dx.are3 vn3 <br /> E. El Of pef)ur) that the <br /> and co..o. <br /> 1 Uswor4ovs PT"ortiestisatk c - _ �. <br /> PH ^e-.e t.xlc fImosibii t ; .., expiasive r. A +r^:� .ter %..,ora to ttre <br /> 17ae sit* operator ah4:e M_iAa., <br /> ..r It ,;__ - gal bersels 0 other State Department of Health vita mowthl7 fee reperta, <br /> 42 y�F spa.. .• <br /> getsinazs: ObW ❑othar <br /> '"(,t <br /> ysical Statot 09.114 ❑I1®aid naludys n other apKi y <br /> Special £sd Iamtrsctiors (i£ anq)+ <br /> Mtaste ie des+e to the beat ot`my ability and It sea delivered to <br /> *,�tqquood liquid vaste hauler (if applicable <br /> i. <br /> 7IQ1 <br /> 14tC <br /> OR OTHER <br /> - , <br /> oertiry4es declare) und•z pesalt'y <br /> of..itiert#*ry-that i1f: forsgoinq is true <br /> ,„4 _. <br />