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Uic 23 Form
ADDRESS
5. TELEPHONE NUMBER
6. FAX NUMBER
7. BILLING ADDRESS
8. EMAIL ADDRESS (Invoice and Approval or Denial will be sent to this address)
9. BILLING CONTACT
10. BILLING PHONE NUMBER
12. TYPE OF E&P WASTE (as defined on back)
01
02
03
04
05
06
11. PO NUMBER (or Other Billing Number)
13. AMOUNT OF WASTE (in BARRELS)
07
08
09
10
11
12
14
15
16
50
99 (describe)
14. DESCRIBE WASTE TYPE 99 (if applicable)
15. DESCRIBE HOW WASTE WAS GENERATED
16. SOURCE OF E&P WASTE (DNR...
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