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Stara of Cald.mio--Environriereal Prpa<yian Agency . <br /> Farm APWowd OMR No:2050-00.19(Expires 9-369e) . See Instructions on back Age 6. <br /> Name prize or type. Farm despised far use on elite(I2yikh)1yp.wnMr. Depamwere of Toxic Subabape Carmol <br /> S.aemwv,Came..,.• <br /> UNIFORM HAZARDOUS I. Generolor's US EPA ID No, Manifest Document No, 2 page 1 hdorm ctimr n dw slsoded:aa� <br /> WASTE MANIFEST a not rewired by Fedvo�1pe Si• <br /> 3i•GeaaeraM's Name and Mailing Address � 1-fi W ilr <br /> o _ t y �I?i r�! CI_�W <br /> Ln <br /> In 4. G.neralal3 Phone lJ��1 <br /> Go <br /> a 5. Transporter 1 Company Name 6. US EPA ID Number <br /> a0 <br /> 7. Transporter 2 Company Name <br /> 8. U$EPA ID Number <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> �� � .•.; l �. Imo. L._ . I I a� -} <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12• Containers 13. Total 14. Unit <br /> J� No. T Duan' Wt/Vol <br /> G Ir <br /> C4 E - d <br /> 00 N b. <br /> °0 E <br /> Nip R <br /> A <br /> T C. <br /> O <br /> � R <br /> ZZ d. <br /> V ' <br /> W <br /> onZ <br /> P <br /> M <br /> ad <br /> Z <br /> Z <br /> Q 15. 5psdd NarlrlGrp kutructions and Additional Information 24 HOUR E `.$P,L`";ItCY . Ri,SPO�tiSI: t]UPJI�r;,t J ,•, <br /> 1147'11 <br /> Z <br /> W <br /> x <br /> J 16. GENERATOR'S CERTIFICATION: !hereby decion,tF.at the conterh of the consignment are fully and accurately described above by proper shipping name and aro classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> U <br /> If I am a large quantity 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 <br /> economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br /> a threat to human health and the enviromnent;OR, if I am a small quantity generator, I have made a good faith effort to mi'+'nimize my waste generation and select the best <br /> N <br /> K te <br /> wasmane ement method that is available to me and that I can afford. ']^"T T7 {J1 T ... 71CT <br /> Q PrSignature/Typed Name Signature Month Day Year <br /> Y <br /> Un <br /> Z T 17. Transporter I Acknowledgement of Receipt of Materials `z, IY <br /> W e <br /> Q N Printed/Typed Name Signature Monte Day Year <br /> � s <br /> w n - <br /> 0 18. Transporter 2 Acknowled ement of Receipt of Materials <br /> LL T Printed/Typed Name Signature <br /> Q Month Day Year <br /> N19. Discrepancy Indication Space <br /> Q F <br /> U A <br /> Z C <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> _ - — <br /> DO NOT WRITE BELOW THIS LINE. <br /> TSC -022A 7 02' <br />