Laserfiche WebLink
9rare or Lalirornia—[nvlranmenral rrotecnon Agency <br />Form Approved QM6 Na- 2050-0039 (Expires 9.30.99) See Instructions on back of page 6. Department of Toxic Su6ston4es Cont <br />Pleasa print or type. Form designed for use on elite (i2-piAj&Il t}raj ..5 - G 1 ` Sacramento, California <br />O <br />u-, <br />h <br />Sv <br />�-s <br />co <br />O <br />O <br />7� <br />Q <br />Z <br />0 <br />a� <br />JL) <br />Z <br />LU <br />W <br />Z <br />VW <br />LU <br />Ln <br />Oa <br />W <br />Ce <br />d <br />Z <br />0 <br />F <br />Q <br />Z <br />LU <br />t- <br />Q <br />V <br />J <br />a`. <br />Ce <br />O <br />V <br />Z <br />3 <br />LJ <br />LJ <br />LL <br />O <br />su <br />Ln <br />d <br />V <br />PRQL# ;'10001519779 <br />DP5','4 �II�99i0000385577 <br />EPA 8700-22 <br />1 <br />DO NOT WRITE BELOW THIS (LINE. <br />31ua GEII;RATOR SEND5 THIS COPY TO DT5C WITHIN 30 DAYS. <br />( To. P.O. 8 400, Sacramento CA 953' 2-0400 <br />��' <br />Generator's US EPA ID No. yanifest Doc <br />2. Pogo I <br />Informotion in the shaded areas <br />UNIFORM HAZARDOUS + <br />C' Du a 3 1 `� <br />1 <br />is not required by Federal law. <br />WASTE MANIFEST tj t <br />OF <br />,� <br />3. Generator's Name and Mailing Address HAR L E Y MURRAY <br />A. State Manifest Document Number <br />1.754 E MARIPOSA <br />2296475c, <br />RL <br />TTN DICY ri1NERB <br />B. Stare Generator's ID <br />O } j n A C4 5 2 0 <br />L .UnTU:' .. <br />4. Generator's Phone h G- J n s •_ C' 2 j v <br />5. Transporter I Company Name 6- US EPA ID Number <br />C. State Transporter's ID ikeserved.l <br />AF ET ;f - :4 L. E E N S' i S T E IM 1 w l l :a; i� 1 s i s x'11) `�- <br />D. Transporter's Phone <br />1^ - .Q_S ^4r <br />7. Transporter 2 Company Nome 8. US EPA ID Number <br />E. State Transporter's ID [Reserved] <br />F. Transporter's Phone <br />9. Designated Facility Nome and Site Address 10. US EPA 10 Number <br />G. State Facili's ID <br />0i'J?,'o5u <br />.Y S 34 i^ <br />SYSTEMS, NC, <br />FETY-KEEN - <br />AL. <br />H. Focillty's Phone <br />700 LAGRANGE ROAD I« Y C15:33451�?}T <br />,t,-TH F+ K', 40058 <br />502 845-2453 <br />1 I. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />2. Containers <br />13. Total <br />Quantity <br />14, Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />a. <br />State <br />RQ TVIASTE PAIN RE—LATED MATERIAL <br />21.1 <br />EPA/Other <br />I Other <br />G3 <br />! '8 3 PG II <br />s l A Y? <br />rxm <br />, '� <br />(,ter09 i( E , <br />U, _� - <br />�-' <br />�r <br />00 <br />E <br />N <br />E <br />6. <br />_ill i - ?3 Ci+t� { a "F' �i` E.L? V �" ^ �--- �- -- •�_ <br />r�-tfiY�Siu���a <br />/ <br />__., <br />_ <br />State <br />- ' «' <br />EPA/Other <br />Ry'� <br />.'� <br />� <br />� <br />Tc� <br />A <br />T <br />c. <br />�'•�� <br />Stale <br />Q <br />R <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />1. Additional Descriptions For Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a14 <br />.A) F003 D04I D035 <br />1.-4 <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />MLFST R/T# 04349527 0003-0592-55 <br />MERGENClY RESP 800-468-1760( 24 HR). IF FJL,4L)ELIVERABLE RETURLi TO GINERATOR. <br />11 k CORP AUTHORIZED TO PETAIN L I:EhTSED SUBSEQUE:YT OA;1VIERS AS NECESSARY. <br />16. GENERATpB'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurarely described above by proper shipping name and are classiFied, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations. <br />IF i am a large quantiy 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 economical)y <br />future human health <br />practicable and that I hove selected the pract+cable method of treotment, storage, or disposal currently avoi{able to me which minimizes the present and threat to <br />and the environment: OR, if I am a small nuantity generator, I hove made a goad faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Typed Name <br />Signature. <br />�MontK� Da Year %7 <br />22 <br />T <br />}'f Transporter 1 Acknowled ement of R4cei t of Materials - <br />R <br />Printed/Typed Nome �� y_ .,, <br />Signature _'- r /t �� } <br />ntCi` lDa nr = <br />A18. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancylndication Space <br />F <br />A <br />C <br />I <br />L <br />l20. <br />Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest exceat as noted In Item 19. <br />T <br />Printed/Typed Nome <br />Signature <br />Month Day Year <br />Y <br />PRQL# ;'10001519779 <br />DP5','4 �II�99i0000385577 <br />EPA 8700-22 <br />1 <br />DO NOT WRITE BELOW THIS (LINE. <br />31ua GEII;RATOR SEND5 THIS COPY TO DT5C WITHIN 30 DAYS. <br />( To. P.O. 8 400, Sacramento CA 953' 2-0400 <br />��' <br />