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-.,mzn-a rnCn _ <br />Costco Wholesale, Inc. <br />TO SCHEDULE SORBENT WASTE DISPOSAL <br />COMPLETE AND FAX THIS CHECKLIST <br />ALONG WITH YOUR RE -ORDER FORM <br />YES <br />NO <br />❑ <br />Are waste storage drums in good condition? <br />❑ <br />Is there any free flowing liquid inside the drum? <br />❑ <br />Are drums clean and free of grease and oil? <br />❑ <br />Are lids tightly secured to drums? <br />❑ <br />Do the waste drums contain any ther than the sorbent <br />material? If yes, explain: <br />INFORMATION NSI NEEDS TO KNOW <br />(FACII M SPECIFIC) <br />Physical Address: `>`Z �r� (Iv- Contact Person <br />-A. L-ty— <br />Qjv` — Phone Number: 7 C 'q-- �K.-� P- ' �- <br />r <br />I Billing Adress: <br />Fax Number: 4— <br />EPA ID #: r N k- Or?.L <br />Store Number: t� <br />Purchase Order #: <br />Number of drums to be disposed of-- Contents of D ums: ' <br />Are MSDS's available for the material being disposed ofl: c1), A Ch0, c <br />mm -+o 0 D U u <br />e Z D S <br />P DOD-. MTMTM <br />C. <br />