Larson & Associates, Inc.
Filtration Specialists

 

Generator Information Transporter Information
Business Name:
Street Address:
Business Name:
Street Address:
City
State
Zip
City
State
Zip

Contact Person
Phone Number

 

Waste Description

Volume in Gallons
Common Name of Waste

 

GENERATOR (Authorized Representative)

   “I certify under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage that system or those persons directly responsible for gathering information, submitted is, to the best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.”

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Date