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state of Cakfa:n.a-Health and welfare Agency See Instructions on Back -' Pape 6 T�S b tae N�Lservices - <br /> Fotm A, raved OMS Na.2060--0039(Expires D,30.91) - ,;.—: and.Front Of-Pag. Saclerremq,CAllig[ma <br /> 'Neaae Drmt a type. Form dealpned foruse on site(1 h typewriter). ^' <br /> UNIFORM HAZARDOUS i. 3a aratorls EPA ID No. —� Manliest 2. Pace'1` Information in,the shaded area <br /> WASTE MANIFEST' oy�am.m No. of Is novrequuad try Federal law'.- <br /> 3. Generator's 1Nam.and Melling Atltl(rp/se �•/ _ ~�,„N MsAaI .OpatslleM 14an6ar <br /> "� <br /> 40f,J ltJ( '�fr� /-A `7 73U a &ate(se waloYq <br /> 4. Generator's Phone ail) - - 'T <br /> S. Transporter 1 Comps Name s. US EPA ID Number C.6raNTnnlpaterfe'ID - '/-i <br /> C� 7. ansporter 2 CompanY Name .. S PA umbo E.a3WeTrapapertirh x. ,. x . ,:, <br /> a ..,Shanyata'►Pirona <br /> 0 <br /> © 9 Designated Facility Name and Site Address 10. US EPA ID umber Q;zstaN <br /> �lUl r �" <br /> J - yyrJW w yA„: A v`, pt <br /> F <br /> r 12. Coolakun 1 .Tol <br /> Q11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity WR , wa4sc,i 4 '. <br /> No. TYPa unit :. <br /> J ,+� <br /> 2 G <br /> 3 •E b. <br /> ti R <br /> r'r� <br /> T ' I':"" rT R Z' ”. - EPAlOew s <br /> N O <br /> R Staip <br /> � a <br /> OCT. 1;6 1992 EPA,011er <br /> w e. <br /> MENTAL HEALTI Srap .. <br /> w PERMIT/ERVICES <br /> J. Additional Deaaiptionti Materials Listed Abe" : Handling <br /> z <br /> 15. Special Handling Instructions and Additional Information <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified,packed.marked,and labeled,and are In all respects in proper condition for transport by highway according.to appiicable International and '- <br /> national government regulations. <br /> t <br /> if I em a bogs calls practicable <br /> generator,I cartiry that I have a program in piece to method d of tr a volume and toxicity of waste generated to the to m ee 1 have nimize the <br /> pr be economically practicable and that t have selected the practicable masof treatment,storage,or have <br /> disposal currently available effort <br /> to me which m y wast the <br /> present and lunare threat to human health and the environment;OR,If I em a smell quantity generator.I have made a goad faith effort to minimize my waste <br /> generation and select the beat waste management method that is availabla to me and that I an aNard. <br /> z Printed/Typed Name - Signature Month Day Year <br /> s T IT. Transporter 1 Acknowledgement of Fligpipt of Materials - <br /> R <br /> A Printetl/Typ..d erne Signature �r Month Day Year <br /> S Y <br /> 4411 <br /> P <br /> O 18. Transporter 2 Act wle gement Receipt of Materials <br /> u <br /> C T Printed/Typed`Name'. . Signature Month Day Year <br /> J E <br /> Z_ <br /> 19. Discrepancy Indication Space - <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Rem 19. <br /> T <br /> y Printed/Typed(lame Signature Month Day year <br /> ,(� <br /> HS 8022 A Do Not Write Below This Lino/ <br /> PA 870 22 <br /> Rev.6-89)Previous edition&are obsolete. <br /> GREEN: HAULER RETAM„ <br />