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. .... ... ........... .. ... .- __-.. . .. _.._...Y.. _. ~ _...-, <br />V . RequlreC CertlTlcatlons <br />a I am the generator of a waste that is acceptable for land disposal in a TSCA-approved landfill. I hereby certify that the waste to be landfilled <br />V "has not been deliberately diluted from an original PCB concentration >600 ppm or deliberately mixed with soil to avoid the incineration <br />requirements of 40 CFR 767.60(a)(1)." <br />b. If this waste contains any equipment that has been drained or flushed, I certify that the equipment has been: ,yor /9p/~,~ASLE <br />G Drained ^ Flushed (check both if applicable) ...in accordance with 40 CFR 761.60(b) <br />'~ ~`~ Fyicc, S. Crc~sb(.f ro I} 9S S1z~k cECcl?eYCcCa - t~tfns; , <br />Generator Signature Printetl Nama Date Company or Attiliauon Ci ({~1 $'~ ~ <br />VII. Shipping Information (49 CFR 172) "" ~ t'~ <br />Proper DOT Shipping Nama DOT Hazard Class UNrNA Number Packing Group Reportable Ouannry <br />24. w^r5~- ~aW e.. r ~ ;• v~ 9 un 2315 ~ I PJ;. <br />Metnotl of Shipmem <br />'. Bulk Liquids ^ Bulk Solids '$~Drums ^ Other (explain) Esnmatetl Ouanury <br />/Yr /Mo y~ /One time only <br /> <br />I certify that all the information required by this farm has been supplied to USPCI with this form. I certify that all the information provided on and <br />with this form is true, representative of the waste, and correct to the best of my knowledge. <br />Ctnrr; S C~tis1-~ <br />, C <br />yt'r~f f\~? i P <br />f~cht <br />qu <br />~ r, (3L~) SicG; -3S7r <br />~- <br />. <br />. <br />, <br />~ <br />, <br />Printetl Naha--, T~,~a 51~z ~;ek(S+- , <br />Telephone <br /> <br />Signature ~ Date <br />RE`/AUG93 White: Faciliry • Yellow: GeneratonerokenW/Acceptance • Pink: Sales Representative • Goldenrod: Comract Admin~orporate • Blue: Generatoneroker's:0riginal <br /> <br />