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y*\ S l u d g e _--.-,-•_„--MO, T o x i c Tank B o t t o m , -.,*_ _"S e d i m e n t /aa-*^ -111. Other T o x i c ^S o l u t i o n s( N a m e ) : — — — — "

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P O O R Q U A L I T Y[ . . . O R I G I N A L

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N O T E : C o n o U t * f o r m (n o r i g i n a l and three (3) enot»*a l a n d f i n e ( I ) c o p y t o d i s p o s a » i »f emora t O E h . o f f o l l o w i n g aonth. *B d t w° ( 2 ) «P1 e s carr iedb a sent C o O k l a h o m a S t a t e

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1 . A c i d S o l u t i o n2 . A l k a l i n e S o l u t i o n3. P e s t i c i d e s4. E t c h i n g S o l u t i o n5 . C a t a l y s t6 . S p e n t P l a t i n gS o l u t i o n7. Brine8. E a u l s i o n9 . T e t r a E t f t y l L e a dS l u d g e0. T o x i c Tank B o t t o mS e d i m e n tOther T o x i cS o l u t i o n s{Name} :

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P R O D J J C E R O K L A H O M A S T A T E D E P A R T M E N T O F H E A L '

Name DduJetl ( P*?MlfAl foP i c k up a d d r e s s / a

T y p e o f p r o c e s swhi ch p r o d u c e d w a s t e •r yi ,t X d f l l p l e * l ( O A * a | " r T f a f i « - > ' — — • " " ••c ' e a S i n g ] « c ! P ' " i r t 9 ' 6 < J U M n T i

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1 2 . C h e a n c a ! f e r t i l i z e rU . C h e a - i c a l T o i l e tW a s t e sCannery W a s t e. Oil16. G r e a s e1 ? . H o n - T o x i cR o t a r y D r i l l i n gHud

1 8 . A c e t y l e n e S l u d g e1 9 . P a i n t S l u d g g2 0 . A s p n a l t S l u d g e2 } . L a t e x W a s t e2 2 . T i l e G l « t ^ste2 3 . L i n e S o d a M a t e r24. S o l v e n t25. N o n - t o x i c Mudand W a t e r26. Other M a t e r i a l sor S o l u t i o n s :

Quantity S l i q u i dga l lons ( V o l . )

P R O D U C E RNameP i c k u p a d d r e s sType of „.,,„„which produc ed was te

S T A T E D E P A R T M E N T O F

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1. A c i d S o l u t i o n2. A l k a l i n e S o l u t i o n3. P e s t i c i d e s4 . E t c h i n g S o l u t i o n5. C a t a l y s t$ „ S p e n t P l a t i n gS o l u t i o n7. B r i n e*, E f f u l s i o n9. T*tra Ethy l LeadS l u d g e)0. Tox i c Tank Bat tornSediment11. Otn«r T o x i cS o l u t i o n s{ N a n * } :

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c l e a n i n g , e t c .)I c e r t i f y that the described waste was d e l i v e r e d to t-il icensed hauler, named be low far I e 9 a ! d i s s o s a l at t?:e

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I c e r t i f y that t h i s described waste was aeeeoted and hzulme to the d i s p o s a l f a c i l i t y i n d i c a t e d above in a vemc l ea v a l i d l i c ense or p ermi t for h a u l i n g s u c / i waste.H a u l e r s p e r m i t o r l i c e n s e H o .V e h i c l e T a g tfo.yz2/_&&. & ' a ' ? ' « : r a ' > _

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1 . A c i d S o l u t i o n2 . A l k a l i n e S o l u t i o n3. P e s t i c i d e s4. E t c h i n g S o l u t i o n5. C a t a l y s t6 . S p e n t P l a t i n gS o l u t i o n7. tr ine8. f o u l s l Q f l9. T e t r a E t h y l LeadS l u d g e10. T o x i c Tank Bot t cmS e d l n e n t11. ( H h e r T o x i cS o l u t i o n s( H a r e ) :

1 2 . C h e m i c a l F e r t i l i z e r1 3 . Oieaiical T o i l e tW a s t e sCannery W a s : eon.o. Grease17 . S o n - T o x i cRotary D r i l l i n gf ed18. A c e t y l e n e1 9 . P a i n t S l u d g e2 0 . A s p n a l t S l u d g e2 1 . L a t e x W a s t e2 2 . T i l e G l a z e t f a s t e23 . Lic e S o d a t f c t e r24. S o l v e n t25. N o w - t o x i c Mudand W a t e r26. Other H a t e n a l sor S o l u t i o n s :( t t a a e ) :

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