Connell Skaggs-LR 931012 Cold Springs Processing & Disposal Service
Texas Department of Health Permit #1225
1 ;~00 Cold ~prings Road · Fort Worth, 'D( 76102 o {817) 332-493g
0515
08708
GENERATOR INFORMATION
,~ t, (MUST BE COMPLETED BY GENERATOR)
BUS,NESSNAME:
· ~ - j ,-' · ---~ /-/ ~ -
WASTE REMOVED FROM: ~S[ T~P
~ GRIT T~P
~ OTHER
I CERTIFY THAT THE WASTE MATERIAL REMOVED FROM THE ABO~E PREMISE5: CONTAINS NO' H~RDOUS
GEN E~TO~REPRESENTATIVE NAME: (P~N~ '
~-- ~T~PRESENTATIVE SIGNATURE)
TRANSPORTER INFORMATION
(MUST BE COMPLETED BY T~NSPORTER)
BUSINESS NAME:
ADDRESS:
TDH REGISTRATION NO:
GALLONS REMOVED:
SAND TRAP SERVICE CO , INC
1300 COLD SPRINGS ROAD
FORT WORTH, TEXAS 76102
TDH ~ 20332
TELEPHONE:
VEHICLE PERMIT NO:
I CERTIFY THAT THE INFORMATION PROVIDED ABOVE IS CORRECT, AND THAT ONLY THE WASTE CERTIFIED FOR
REMOVAL BY THE (GENERATOR IS CONTAINED IN THE SERVICING VEHICLE. I AM AWARE THAT FALSIFICATION OF
THIS TRIP TICKET MAy RESULT IN, PROSECUTION.
RINT)
(DATE AN 6 ~ME WASTE ¢~s~RTED)
(DRIVER SIGNATURE]
DISPOSAL INFORMATION
(MUST BE COMPLETED BY DISPOSER)
BUSINESS NAME: Cold Springs Processing
ADDRESS: 1300 Cold Springs Road; Fort Worth, Texas 76102 TELEPHONE: 817-332-4939
TDH REGISTRATION NO: 1225
I CERTIFY THAT I HAVE BEEN AUTHORIZED BY THE TEXAS DEPA~~HEALTH~~_~~= TO ACCEPT THE ABOVE
SPECIFIED WASTE AND THAT I HAVE DISPOSED OF THE WASTE IN A~~~THE REQUIREMENTS OUTLIN ED
(DATE A~qD TIME W*~STE ~ECEI~-'~ED) v ,,1~,?~. ,_ ./ ?L~¢.~..~.~ /~(~S~I~, CPERAT~OR S~GNAT~--~ RE)