Connell Skaggs-LR 930403 Cold Springs Processing & Disposal Service
Texas Department of Health Permit #1225
1300 Cold Springs Road · Fort Worth, TX 76102 · (817)
1993
GENERATOR INFORMATION
U,'~ ,/ (MUST BE COMPLETED BY GENERATOR)
WASTE REMOVED FROM: ~ GR~SE T~P
__ GRIT T~P
OTHER
WASTE TANK OR T~P CAPACITY: GALLONS
I CERTIFY THAT THE WASTE MATERIAL REMOVED FROM THE ABOVE PREMISES CONTAINS NO H~RDOUS
MATERIALS ~
(D~TE SERVICED) (GENE~TO~EPRESENTATIVE SIGNATURE)
TRANSPORTER INFORMATION
~1 ,~ (MUST BE COMPLETED BY TRANSPORTER)
ADDRESS:/ c, v:
TD" REGISTRATION NO:
GALLONS REMOVED:
VEHICLE PERMIT NO:
TELEP.ONE: 9'77' 5¢.0
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.
DRIVER NAME: ~6 ~?' j
(DATE AND TIME WASTE TRANSPORTED) (DRIVER SIGNATURE)
DISPOSAL INFORMATION
(MUST BE COMPLETED BY DISPOSER)
BUSINESS NAME: Cold Springs Processing
ADDRESS: 1300 Cold Springs Road; Fort Worth, Texas 76102 TELEPHONE: 817-332-493g
TDH REG~STRAnON NO: 1225
~ C£RT~F¥ THAT ~ HAVE BEEN ^UTHOmZED BY THE T~S DEPZRT~E~T OF H~T"?~~H~.Z~OW.,~,~,.
SPECIFIED WASTE AN D THAT I HAVE DISPOSED OF THE WASTE IN ACCORDANCE WITH TH~ ~ ~LINE D
IN THATAUTHORI~TION./~ ~ ~ ~ ~);:
(DATE AND TIME W~TE RECEIVEd) ' ~ - ~ ~E~bR SIGNATUREi
WHITE - City GREEN - Diqx~ll YELLOW - City PINK - Generator GOLDENROD - Transporter