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Vnntor IeaNO.2050--0039(Expires 9-30-88) <br /> x Form tlnsi nntl/or use on elite 12- 11th f ewrifer. Depsnmenl of Neal". <br /> UNIFORM HAZARD Toxic Subatences Conn,. <br /> I. Generator's US EPA ID No. Secremumo, <br /> WASTE MANIFES C4c 'e°' 2. Page t <br /> 3. anerelor' l <br /> G 7 Do . a t No. of ,Information in the ahadud .. <br /> PN e and Mlinp AtldrOf is not required by Fedurel i <br /> I I lt'f/ �;JT ///3 A. 6lata Manifest Document Number <br /> Nr�M� C[AgS32�/ 87955059 <br /> 4. Generator'a Phone 57 _ B/S�taN Oenualor's ID <br /> N 5. Tr So aLr I `om any Nam �U l� t <br /> /p a US EPA 10 Number C. Stale Tranapotler'a IDG <br /> m 7. Transporter 2C me `' D �/ k� l D. Transporter phone -- <br /> o ( , . H'j�U� / T 8' tUS EPA ID Number p <br /> o VV I ` L E. State Trane oner'e <br /> m /ICS 'l <br /> 0 Design led Fac 111 area a Sile Adtlreu G Y F. Transponer'e Phan 4 <br /> J , � 10� US EPA ID Number <br /> < LJQrytUr pGn �'1 . _G G. Slatfr Facility's ID <br /> Z CM _ ^ CIS ��j�„�rl o 3 H. Faci Y's P one <br /> ¢ ✓� f a� c rS3 7- 7 cc, <br /> u. I 1. US 00T Description(Including Proper Shipping Name,Hazard Glass snit ID Number) 12. Cont here 13. T lel <br /> < Unit <br /> I. <br /> U e. No. Type Quantity Und Wsnt.h <br /> Inru� Ee f L Wt,ya <br /> FG ^^G( SAM G GSY/G !�GI St.. <br /> N -4/A <br /> E b. l 6 4 O G EPA/Olh.r <br /> 0 R <br /> m A <br /> m T Slate <br /> e <br /> n 0 <br /> a R c EPA/Other <br /> O <br /> 0 <br /> m <br /> Stasi <br /> ¢ <br /> w tl. <br /> EPA/Otho, <br /> F <br /> ad <br /> w <br /> I <br /> L) Stale <br /> w EPA/Other <br /> Z J. Additional Descriptions.-.Materials Listetl Above <br /> a K. Handling Codes for Waetua Listed Above <br /> b. <br /> Z d. _ d.- <br /> 0 <br /> r 16. Special Handling Instructi ne and <br /> 2 itionM Inlormstlon ..a <br /> - <br /> w <br /> 2 <br /> ti <br /> J , <br /> J <br /> a 16. <br /> U <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above b <br /> J name and are classified. p Proper Packed marked, and labeled, and are in all res acts in ro er condition for transport by highway accordingo oeappllco, <br /> a <br /> international and national government regulations. <br /> m If I am a large quantity¢ d q Y fleneralor, I cerlily That I have a program in place to reduce the volume and toxicity of waste penaratud to the degree I lie. <br /> U determined to be econom scally practicable and that I have selected the practicable method of treatment, storage, or neratod currently avail abh: <br /> me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a go, <br /> lailh effort to minimize my waste generation antl select the best waste management method that is available to me and that I can afford. <br /> Z <br /> w Prinle p d Nam <br /> 7 <br /> ¢ i Signature <br /> � ii 7 Mouth Day <br /> w R I1. Trensponer 1 Acknowledgement of Receipt of Materials <br /> Z A Printed/T pd ams <br /> N - Sipnaturo <br /> S ^ MMonthDny <br /> 0 <br /> o P O <br /> w O I8. Tre p her 2 Acknowledge MI of Receipt of Mtlariaie <br /> UR Printed/Typed Nam. <br /> E Signature <br /> zR Month Dey <br /> lg. Dieorepency Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Openlor Certa cation of receipt of ha:ardoua materials covered by me menitaet except es noted In Ilam to. <br /> TPrinted/Typetl Nama <br /> Y Signature <br /> Mon III Day <br /> DNS 8022 A(I/871 <br /> EPA 8700-22 While: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> (R•v.9.86) PISVIOUS editions are obsolete. To: P.O. Box 3000, SOCIamitnto, CA 95812 INSTRUCTIONS ON THE BACK <br />