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See Instructions on back d,,/dge 6. Depaament of m.ia sebsmnas can::_: <br /> . .. _ . . sarramema,Celif.-m <br /> • —- - - - -- _ - - E D r:a. . . nCcv Document No. i 2. Page 1 I Information in the shaded revs <br /> I F is cur egsfired by Federal law. <br /> - T 9 1 4 5S 7, 3 1:f <br /> D. <br /> i <br /> _ '�c <br /> 9 <br /> U Fr ID umber E. State T anperr_r s 10 — <br /> " � �F T.rcncpar;ea F`on <br /> i <br /> A.dd: s I0. 1;.5 G'A ID Number G. Sic Fa 'ty's D —• <br /> I. <br /> 71 91 17-1-44�fA <br /> I r q e P CI- .rd ID Number) 12 Cono veU.rs Tat ld Unrt <br /> No Type Quantity -I} Wt/Vol 1 \vests <br /> t LIC.'sl ? <br /> i'/ <br /> .;rL-tet;£) ix� 1 T I L: y � G hpC1:�J°rv�aP', <br /> b' state <br /> n' B <br /> � EPA/Ocher <br /> Stale <br /> O <br /> R EPAi Uho, <br /> r 11 <br /> State <br /> u - � <br /> ,+ EPAi Otber <br /> —. <br /> J. Add ianal Descriufcns for Materials lis!ed Above K. Handling Codes 1.1 Wostvs Listcd Above <br /> ERG 31 6. <br /> t: <br /> iC. d. <br /> r15.. Special Hondiing Instructions and Additional Information24 HOUR EMERGENCY RESPONSE P:L��ER 1 {gyy7) 399--1357 <br /> 1A. PROFILE ':;191—P <br /> I <br /> G°NERATOR's CL.'.TI FICA TI ON: I hereby declare thot the contents of this consignment are fully and accurately described above by proper shipping name and ore classified, <br /> pocked,marked,and labeled,and ere in ull respects in proper condition for transport by highway according to applicable international and notional g.,ommarl regulotlons. <br /> If I ora a large quantity generator, I certify that 1 have v program in place to reduce the volume and rozicity of waste generated to the degree 1 have determined to 6e <br /> _' ± emnprniccl!y pr,ficaLle and that I have selected the practicable morhod of treatment,storage,or disposal currently available to me which m nimizes the present and future <br /> i3{9i threat to humors haoith and the environment; OR, if I ani a small quantity nemtar, I have made a good faith ffort fo imi a y waste generation and select the best <br /> wn to manecem+nt n,e!had that i+available m ma and that I can afford. 01 EEHALF OF DEC!'S AUTO REPA 1 R <br /> (j PrinredjTypad Nn n:e Signature Month Day Year / <br /> � . .may e <br /> s V. Lonsporter i Ac!.no edger nr of Recei 1 of Ma+erials <br /> A Panted/Typed Plume Signature <br /> O H , g Month Day ar. <br /> �. 0 18. T,.m,,Ie,2 Acknowledgemwt of Receipt of Materials / <br /> Printed T N <br /> I l YPdome° Si otvre Month Day Year <br /> IF <br /> fll e <br /> +: 19. lbscreparcy Indicotmo Space <br /> F <br /> U A <br /> C <br /> -r I <br /> L <br /> I 20. FaufiN Owner or OCernmr C,:,ftmtion of receiot of Lazardous ma_tedals coverVLOWIS <br /> ted m Ite 19. <br /> T Primed/Typed N,me bignaNre Month y yerar <br /> Y t / C <br /> DO NOT WP,rT <br /> ':C B@2A (9/93) h.: _ T] D'.'E. <br />