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WASTE PROFILE SHEET <br /> _ CODE NO. /��� �J–�¢� <br /> WASTE SHIPMENT RECORD '�'J ��' <br /> . 24 Hour Response Telephone Number <br /> . YIIASiE MANAiOEMEMT ' <br /> t.A Geq4eretod0 er me and fte address GeneratodOwner Corqact name Ge�eratoNOwner <br /> C i t'+� p� �.Ge,��"'�f'' ���, �� telephone no. <br /> 00 �� �� o� Wci..�" � <br /> •�.r , ba�� �'{'o w�a�r ���-yz�`d4�,� <br /> 1.B Generator/Owner e and ailing address ` � I � Gen��e��/Owner <br /> e.�� � v�✓` � 0+�0►�w�C�. Q►�l� rban � o�n�'�' <br /> .t �irGC �Ovr �v'�' �1� <br /> �F.1. �'s,o�r ,.� �i�cc r�. , �i2..5 Z���NZK�Z7Z? <br /> 2. C ntractodOperetor—na�►q,and a reas CoMractodOpe►ator <br /> � � �^f�._ y��r�� '�L� telephone no. <br /> ,d�.�1l.i <br /> �°� �X f� S'�3-336 s�g� <br /> i w <br /> 3. Waste disposal site(WDS)neme,maflinp address and phyeical sfte bcaHon WDS telephone no. <br /> FIVE OAKS RDF <br /> 890 E. 1500 NORTH ROAD,TAYLORVILLE, IL 62568 . 217-8243942 <br /> � �N.,... <br /> Q4. Name and addresa of responsible ager�cy <br /> ¢ I. E. P.A. <br /> W P.O. BOX 19276,SPRINGFlELD, IL 62794-9276 <br /> c� <br /> 5. �ripdo�erials 8. Contebiers 6. Total QuaMily <br /> No. Type Cubic Yarcl� <br /> � <br /> 2'G,� c�o�7�� d a s 0 � <br /> �( c�. 6�n ef <br /> 8. Spkial Hsndling tn�tructia�s and AddltlonN Iniormatbn <br /> OPERATOR'S CERTIFICATION:I hereby dectare that Me contents of this consignment are fuUy and eccurately descibed ebove by proper shipping name <br /> and are classiNed,packed,marked,and lebeled,and are in all respects in proper condidon Mr trarrepoR by Mgh�y aa:ordiny W appUcable intemallonai <br /> govemment regulatlons. <br /> 9. (3ENERATOR/OWNER CERTIFICATION:1 hereby declere that the conterns of this consignment aro fully and acCurately descibed above by proper ship- <br /> ping name and are classiffed,pecked,marked,and labeled,and are fn all respects in proper condftion for tra�poR by highway according to applir.able <br /> intemaUonal and natlonal govemmeM regulatlon8. <br /> Printedftyped name and tltle Signatu MoMh Day Year <br /> �'�'�-- T`c�/rac J �,�Qr- - � o q_�_�� <br /> 10. Transporter Name 1 (Acknowledgement of recefpt of materials) <br /> P <br /> TranspoRers Address Telephon No. , <br /> L <br /> J Driver Name/printed or typed � ` Signature . Month Dey Year <br /> � � � � . <br /> c <br /> Z 11. Transporter Name 2(Acknowledgement of recd�t of materials) <br /> 5 <br /> Transporters Address Telephone No. <br /> Driver Neme/printed or typed Signature MoMh Day Year <br /> � 12. Discrepancy indication space <br /> � <br /> � 13. Waste disposel site owner or operator <br /> QCerti)icafion o/receipt o/as6astos materlals casred is maniAes except as noted in N t <br /> N P�inted/typed me an tur � ; h Day Y r <br /> � r <br /> ._ �ri <br /> ORIGINAL WHITE-Landfill GREEN-GeneratoNOwner(Mailed hom Landfill) CANARY-Hauler PINK-Contractor GOLDENROD-Generator/Owner <br />