K&M Diversified, Inc.

LOAD REJECTION NOTIFICATION FORM

Waste Load Information:
Was Entire Load Rejected?

_______ Yes _______ No

Date_______ Time_______

Explain: ________________________________________________________________
Waste Information: ______________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Waste Hauler Information:
Trucking Company/Waste Hauler: ___________________________________________
Truck License Plate Number ____________________ Truck I.D. Number ___________
Driver Name: ___________________________________________________________
Hauler Address:__________________________________________________________
________________________________________________________________________
________________________________________________________________________
Waste Generator Information:
Site Location:____________________________________________________________
________________________________________________________________________
________________________________________________________________________
Contractor Name:_________________________________________________________
Contact Name: ___________________________________________________________
Person Completing Form:______________________ Location: ____________________
Received SNHD Regulatory by: ___________________________ Date: _____________
Faxed to SNHD: ______________________ Fax # ____________ Date: ____________