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TEXAS NATURAL RESOURCE • p4&OP • <br /> CONSERVATION COMMISSION s�, TFD <br /> P.O. Box 13087 <br /> r � <br /> Austin,Texas 78711-3087 - <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form approved.OMB No.2050-0039. <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2. Page 1 nformation in the shaded areas <br /> . U nt of is not required by Federal law. <br /> WASTE MANIFEST 1 21 ' <br /> 3.Generator's Name and Mailing Address , , .. . A.State Manifest Document Number <br /> 500848762 <br /> B State nerator's ID <br /> 4.Generator's Phone - <br /> 5.Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID - -- <br /> .. 1.1. ,��• D.Transporter's Phone <br /> _ .. . 1... _ <br /> 7.Transpo 2 Company Name B. US EPA ID Number E.State Transporter's ID ��p(j <br /> 1 A2000000151c0 F.Transporter's PhoneslDC" 25-8 <br /> 9.Designated Facility Name and Site Address->: _ 10. US EPA ID Number G.State Facility ID <br /> H. Facility's Phone <br /> ?y, 762(7Yl <br /> 11A. 11.US DOT Description(includingProper Shipping Name,Hazard Class,ID 12.Containers 13. ta. I. <br /> p p pp g No. T e Total Unit Waste No. <br /> HM Number and Packing Group) yP Quantity Wt/vol <br /> a. <br /> N }i'H'1 i I ! FRC:5.1 ^ <br /> E b, <br /> R WASTE rA "'IT RCIL_7.TED MATERIi,.. I <br /> A ;z ) E „ ll� <br /> T <br /> 0 <br /> R C. <br /> d. <br /> ditional Descriptions for Materials Listed Above _ K.Handling Codes for Wastes Listed Above <br /> b fc <br /> 15.Special Handling Instructions and Additional Information <br /> CAF.F' <br /> 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are <br /> classified,packed,marked,and labelled/placarded,and are in all respects in proper condition for transport by highway according to applicable international and national <br /> government regulations,including applicable state regulations. <br /> It I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health 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 <br /> the best waste management method that is available to me and that I can afford. <br /> rUoted/Type Na rn� '` $igRa Month Day Year <br /> 33 �t /l9� b Somt:T 3 <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> A Printed/Ty ed Name <br /> Sign re Month Day Year <br /> N <br /> S <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials - Date <br /> Signature Month Day Year <br /> R Printed/Typed me // � 4 JcY <br /> R <br /> 19.Discrepancy.Indication Space <br /> F <br /> A <br /> c <br /> 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item <br /> 19.I Date <br /> v Month Da Year <br /> Printed/Typed Name I.a a t I Signature <br /> TNR¢C,-.0311 (Re' 07/01/g71 _ hite-original Pink-TSD Facility Yellow-Transporter Green-Generator's first copy <br />