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Resource Recovery Program <br /> P.O.Box 24055,M5 702 <br /> Oakland,CA 94623-1055 TRUCKED NON-HAZARDOUS WASTE DISPOSAL PERMIT <br /> (510)287-1336 Fax(510)287-0621 Terms and Conditions <br /> EBMUD Addendum A <br /> Waste Acceptance Agreement <br /> I certify the description of the waste below is a true and accurate representation of the waste stream and any changes <br /> to the below described waste stream will be disclosed to the EBMUD Resource Recovery Program for further review <br /> of waste acceptability. <br /> 1) �aQV co-J2�1� _ 2) SIV 2_3 T2 — <br /> PERMIT HOLDER (Tobe completed by ESMUl3) PERMIT NUMBER (To be completed by EBMUD) <br /> 3) � _ 4) <br /> Customer Waste Name (To be completed by EBMUD) Waste Type (To be completed by EBMUD) <br /> 5) Source of Waste Stream to discharge: <br /> a.Generator/Site Name b. Site Address c. Waste Composition d.Estimated Total Volume <br /> 0/Lo-�� n5 .i.il tri6-"� (0V"6 14_7rl-- ti,v 5 JV u 1•Vie—' Oil <br /> W(e..�g. sludge,liquid) (gallons/per event or on-going) <br /> 6) Estimated Delivery Dates: 2©O — c>;.1; Ov— Delivery Frequency: _M F- 3 cicu J <br /> Ex:(April 16-30,2006) Ex:(M,W,F (3)loads/da <br /> 7) Is the process generating waste subject to Federal Categorical Pretreatment Standards? Yes NoDll" <br /> If yes,indicate Federal Categorical regulation and if in compliance with requirements? Yes NoF7 <br /> 8) Describe process generating waste and its known and potential pollutants. ` <br /> • ►tea. �► llz them �� 'E'( �� t 4 tx� <br /> 9) Fees for Discharge of Trucked Waste <br /> The disposal rate is based on the waste type indicated on this form and as listed on the EBMUD Schedule of Rates and <br /> Charges. EBMUD reserves the right to revoke a permit for past due payments. <br /> 10) P.O.or job number(if needed for billing reference): <br /> Permit Bolder(or duly authorized representative)Is Signature: <br /> VJ�� Cs� �• 'L� i © 1# i� D' I <br /> Print Name&Title Sig tore Dfate <br /> COMMENTS: <br /> EBMUD Resource Recovery Program Decision:Approved M Re'ected Expiration Date: <br /> Signature: Date: <br /> FOR EACH LOAD,PROVIDE COPY OF THIS FORM TO GUARD KIOSK <br /> Revised 4/2iO4 <br />