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17 I'Arju Iui , - w x f r I r e <br /> !'refile iso.-,�ir Expiration Dain �_20V_p <br /> WASTE AC C EPTABILITY APP LI A TI0N, V 0 L C 0 U NTV CENTRAL LAN DFILL <br /> Instrurtlluns: Complelt:this form andatmc]t ooalylital and FAX to(530)666-8853 or email to 0o a u lac u a or <br /> ma - ancs oJacoun .a or'cfFkicFi' [or:au I .o lies#ions, Pic=zonlact 53D-666-8726 <br /> ;VAST£IhlFORMATIOh' <br /> WastcTypE(Circle rmzl3)CLEAN SOIL ?)CONTAM[NAT 1)SDI4 114TIIER [slwcify}: �rt� C�YC� <br /> Apprax-amount: %D (cubic ywds or It1113(circle)) <br /> Wlhot pmi"If lettvily generated thtf.wale? '%am u�b%+ . - �- <br /> UeAddncss; 5�S ht- W+a.A _ Ijr City; SG o"L zi[F=_rt'tS2_1n7_ <br /> Ar li eipatcd First Day of l laul. 'u1y I I- 2011 Antielpated Ifirst day orliaul: - <br /> YES Q NO E'{1rTiown ar suaperled contomingats'? if yes.�mr,idc at�alyli al,(anulytico[slam oppli€a#ian may 6e required} <br /> YES[) NO2-7 nown special handlingrim4b' IfyL%,sileciry _ (atklllianal fcssrWYUpply) <br /> VESE)❑ N ©'T#n7si rial wrl? -Muss he l+ss than 5[I'h maisturc and 1717 Free lIgtaid to lfc satin%miir,inkswise sort liquid wa,Ie x licalion <br /> YTLS O Annlyrlcnt data andlorMSDS provided'Analyticml data rnestfc from C,-rlifo[stiaSI-de Certifted L-ubnratory <br /> YES C) No 21kns a permi I I&s ued Far tht-pru jus? Permat ti and issuing iigeney; <br /> TRANS PORTER FNFOFtAIATION <br /> Company Name&Addresr' — <br /> lhivrr'sjDispa[ehcr Alpme:-- Phone it{office,rnnbi19,Page* <br /> Vehicle¢arm6ty Q 11 Semi-end dump. 2)haticrm dump.E '3}Roll-off Or e11.13 dUITIV.❑Other` <br /> WASTE GENERATOR I�NF0PU%1ATTOI'd <br /> Company No mecmdAddress: r%% dVir l-M16 <br /> grojcct Marosgcr Nama ONtit— pyre_ __T _Moor N(affice,nrob[]c,xl&gr4l <br /> Address 4 l - WIAW Crly; r°c> ruwl Zip. <br /> l'ypearbusattcts(tralCifitisaresirlrnec); k'1*1cF5 C< %En <br /> Pa)rruet4t McUiod: Cash ❑ Chvd. [1 Crcd it Card 0 Landfill Account <br /> CFRTIFICATi•ON <br /> The 1YA54c GococrWor cerlifacs[hal this applivn1ion nand any atluchexl inl`onrtaiion are uuc uW wunmte ar.d mprusentutive 0FLha subjW waste. Waste <br /> Garth sur Nmif es thul lke3;rc has dis6osed al rc[evora in rumul ion an kri own or suspcctad canlurrunonLs aad a6mtands that thea,~napY t}c <br /> nd�litiot>ttl forts ahaald onluznirLOftIS I C du vere+l lkoat won:loot disclostel by Cacnsra{ar, Gcnetstor Cenifics Lltal this W SIC s]oef real ronstcute a <br /> Haze lour Wase is as deftncd by Stale of California under Sculon 6061-3 ofTil le 22, Division 45,C wplcr 11,Article 1 of the Cali mania Cc de of <br /> Rrj,rululimns (22 C.C.K 6261.3)- If Lhisnppliw1on is oarnploted on behalfof0em nlur,Applicmi certifies Shat hd-;bc has ibc rull ntltho itytobind <br /> Gcsseratur to These terms and rwnditions, App[icant jLVrC 1O be j"y and ser ally liablc%YiIli riencmtor rear all infotuta=inn and wTru-woutloas <br /> pm+idW herein, <br /> {Gmtralor of,Audios RcpmxmtndVC) <br /> *##■TO RF C{7MPLET&D 8 RORIZED COEJl1IT7,`PERSONNEL••* <br /> WAM APPROVED? YES O NO❑ Approves]By: pale; r <br /> Acouunl#: 24interial: {]tlgin_ Grid, <br /> FEES.- MWSal 11„ Special dandling S <br /> Sf=ial tnamctions(handling. fres, hauler.CIC.,) <br />