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Prase or 4anmre0—maadm and Welfare Agency <br />Form Approved OMB No. 2050--0039 (Expires 9.30-88) <br />Department of Health Suty cva <br />Toxic Substances Control Drvuton <br />z a t drl INSTRUCTIONS ON THE BACK <br />� <br />89YELLOW: GENERATOR RETAINS <br />v. 9-86)86) Previous editions are obsolete. <br />UNkFORM HAZARDOUS aha US EPA ID No. Menileat <br />e 1 Information in the shaded areas <br />WASTE MANIFEST G u Document No <br />of snot required by Federal law <br />3. GPlnarelor's flame and Meiling Atldreae <br />A. State Manifest Document Number <br />/43 <br />/.4 / /'i ia, � 1, <br />S. State Generator's ) <br />1. Generator's Phone (1 ) %• _ / - I ( _ " <br />,t <br />/ <br />i- <br />/ <br />5. Transporter I FdrnpapY Name e. US EPA ID Number <br />C. Stale Trane oiler's ID <br />v r-- <br />D. Transpodeis Phorrs) ! :7. 0% <br />1. Transporter 2 Company Name e, US EPA ID Num e/ <br />E. Stale Teensporter'AID <br />L4 41, 14 y I} <br />T. Transporter's Phone, <br />9. Designated Facility Name and Site Address 10. P US ID Number <br />G. Slate Facility's ID <br />i <br />Fe ildy's Phone <br />_ <br />- <br />/ <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class, and 10 Numbed. <br />12. Containers <br />13. T tat <br />Quantity <br />11.' <br />Unit <br />1. <br />Waste No. <br />No. Type <br />WI/Vo <br />G <br />a. { <br />11 <br />.. L. C,11I T UGi>4 b l <br />/4.: 46ld(� <br />Stater <br />E <br />�L. _ <br />EP /Other <br />N <br />E <br />R <br />b. <br />I <br />Stale <br />A <br />EPA/Other <br />T <br />O <br />R <br />C. <br />Slate <br />EPA/Other <br />d. <br />Stale <br />EPA/Other <br />J. Additional Descriptions for Materiels Listed Above <br />K. Handling Codas for Wastes <br />Listed Ahoye <br />a. <br />b. <br />d. <br />dal <br />15. Special Handling Instructions and Additional Information - <br />i <br />I <br />r <br />a I <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipp� <br />name and are classified, packed, marked. and labeled, and are in all respects in proper condition for transport by highway according to applic.,.., <br />international and national government regulations. <br />11 I am a quantity large g q y generator, I certify that I have a program in place reduce the volume and toxicity of waste generated tthe degree I h ..n <br />pr c <br />determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currentlyy avmlaLIP I <br />a,,a <br />me which minimizes the present and future threat to human health and the environment: OR, it I am a small quantity generator, I have made a g,od <br />faith effort to minimize my waste generation and select the beat waste management method that is available to me and that I can afford. <br />Printed/TY tl me / <br />y1 <br />Slpnalura / Month Day Year <br />Ile <br />;, , C <br />T <br />R <br />17. Tra porter 1 Acknowledgemarrilt of Receipt of Materials <br />S <br />Printed/Typed me <br />Signature Month Day Year <br />/•, <br />P <br />R <br />18. Tranaponer 2 Acknowledgement Receipt of Melenals <br />Printed/ Typed Name <br />Signature <br />g Monrh Day Year <br />E <br />7 <br />1 <br />l <br />, l <br />19. iacrepancy indicationSpace <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />20. Facility Owner or Operator Codification of receipt of hazardous materials covered by this manifest except as noted In hem 19. <br />Y <br />Printed/Typed Name <br />S1 nature <br />g Month Day Year <br />z a t drl INSTRUCTIONS ON THE BACK <br />� <br />89YELLOW: GENERATOR RETAINS <br />v. 9-86)86) Previous editions are obsolete. <br />