Laserfiche WebLink
State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-00391 Expires 9-30-♦ See Instructions On t of Page 6. Department of Toxic Substances <br /> Please print or type. Form designed For use on alms�s.-,Atch)typewriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Pogo I Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST P " 1.+ L { " . of j <br /> 3. Generator's Name and Mailing Addresy` A. Manifest Document Number <br /> ..L.= .� � h .� = 217509E <br /> ya..'4;t ^t! B. Stale Generator's ID <br /> sod. Generator's Phone 1V ^I-a" _ <br /> 54 <br /> N 5. Transporter I Company Name 16. US EPA ID Number C. StateTronsporfer's ID Reserved.1 <br /> N ar�s <br /> O iflnitYGt1 r • a i g e 2 D. Transporbi s Phone `yy <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number 9 i • E. Stab Transporters ID Reserved.] ifi <br /> F. Transpor-er's Phone <br /> 9. Designated Facility Name and Sim Address 10. US EPA ID Number G. Stale Facility's ID <br /> C" IO Z � f i.("1,, !^u ;.i;:x-::✓f �.a'}.s..`il4 N �s�'�.. .. i f 4 4 4 1 1 <br /> W 1021 WIM H. Facility's PhoneLID '' <br /> Issi Inkmil-ASSM Ic 1A 10 10 is 19 1& <br /> 1110 <br /> VJ I1. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number 9 12. Containers 13. Total ±d. Unit <br /> p 1i 8 W ppi 9 I No. r Type Oaanlily Wt/Vol L Wash Number <br /> N= NDff Ai�h=0JbfRsr 8ft Gl3W Sin tai <br /> Eo t t..b( . J��f fJ�4.:_ 1,0 4/' `�/.rY o. State <br /> N <br /> an E so I.ti r f f P� "�.^ EPA/O1h.r <br /> O T a. Slate <br /> m O <br /> R EPA/Other <br /> w d. Stile <br /> Z <br /> Z <br /> W <br /> V EPA/Olher <br /> W <br /> Z <br /> J. Additional Descriptions for Materials Listed Above K. Handling Cade.for Wastes Listed Above <br /> O a. b. <br /> '1I11FgA1RsT1tlIR1► <br /> C d. <br /> Q <br /> Q15. Special Handling Instructions and Additional Information ' <br /> a 24 HIIIN Emerpmy Response T¢!.Ho.CH%RtfHEC 1-D-424-93M <br /> DDf tX V+td, ww Grotectilet eoullfig t3H!of t.adIng# rid ,1 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contsnls of this consignment aro Fully and accuraMy described above by proper shipIng name and are classified,pecked, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and nalionaPgovernment regulations. <br /> If I am a large quan8y generator,I certify that I have a p ram in place to maloce the volume and toxicity of waste generated b the degree I have determined to be economical <br /> S practicable and that 1 pare selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heal <br /> and the environment;OR,if I am a small quantity generator,I have made a good Faith effort to minimize my waste generation and select the best waste management method that <br /> ac available ta me and that I can afford. <br /> O <br /> > Prinled/Typed Name '1 f Signature __ Month Day Y <br /> W T 1V sporter l Acknow mment of Receipt o Materials <br /> w Prinled/T Name Siffnature Month Day, Y <br /> W B 1 B. m "ter 2 Ackhow amen of ecei t of Materials <br /> O RT P .wd/Typed Name Sigdature Month Day Y <br /> w E <br /> sn R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 20. Facility Owner or Operator Certification of recap t of h....dous materials covered by this manifest..pt as noted in Item 19. <br /> T Printed/Typed Nome Signature Monde Day Y <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A 11/991 r:� OP, RE fAl h <br /> EPA 8700-22 -�" - �� <br />