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- - - -- -- - - - - - - -- - - - - - - - - - - - - - - - -- -- <br /> gate of roved ie B No.h and Welfare Agency • Department of Health ServiCIM <br /> am Approved OMB No.2050--0039(Expires 9-30-88) Toxic Substances Control Division i <br /> ease print or Woe. (Form desi netl for use on elite(12- itch f ewrifer). Sacramento,California <br /> UNIFORM HAZARDOUS Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST r i I K 11 n ? ��i <br /> Copy LMo. of /�l I11 is not required by Federal law, <br /> 3. eeneralot, ,d Mailing AtlNell j�_- A. State Manife uLpeoumpie N bgr I <br /> 61 4 <br /> - B. State Generator's ID <br /> a. Generator's Phone(4/!7) f' 7 <', i' <br /> 5. Transporter I Company Name <br /> /T C— e. /;9J US EPA ID Number C. State Transporter's ID ()/ <br /> Y/ � E� <br /> 'QO — � s.�:✓/�� 1/-IC a e)18/ I S/S-5; IV D. Transporter's Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> F. Transporter's Phone <br /> 9. Designated Facilit Name Its ae 10. US EPA ID Number G. State Facility's ID <br /> ,,6,1p t` <br /> CC.m/H��Gi.)—fwc�. G 9 8 f / 77 <br /> C H. Facility's Phone <br /> rA O 1 e I FI / 771 ar)-_- -2/78 <br /> 12. Containers 13. Total 14. I. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> No. Type WI/Vo <br /> Starts_ <br /> N TAn/rG GGiT vn +G /-/�s9TE. f�/owK O T O �' ,�(°tahsr <br /> ✓ <br /> E b. <br /> R State <br /> I <br /> A <br /> T EPA/Other <br /> O <br /> R C. State <br /> EPA/Other <br /> d. <br /> State 11 <br /> EPA/Other 1 <br /> J. Additional Descriptions Ior Materials Listed Above K. Handle o f ' tqd v� • <br /> �'S <br /> C. <br /> Oemg�umCT 2 6 1989 <br /> 15. Special Handling Instructions and Additional Information <br /> PERMIT/Sr- luES <br /> <✓G't_�i� ���S /�L-�C-'G�.S !�/�:ii<%1i din <br /> te. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> international and national government regulations. <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 <br /> determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <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 good <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br /> Printed/Typed Name 3{pn uro � Month Day Year <br /> Tit V %- i l/ < <br /> R17. Transporter 1 Acknowledgement of Receipt of Materials !:-- <br /> A Printed/Typed Name /J Signature <br /> S ti..�L.S (,I_.) U` � A l �.J I/�Y // Mont^Day Year <br /> P , <br /> LL <br /> D 19. Transporter 2 Acknowledgement of Receipt of Materiels � I <br /> R Printed/Typed ed Nama <br /> T YD Signature Month Day Year <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> 1 20, Facilely Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/T ed Name <br /> Y YD Signature Month Oay Year <br /> IIIII <br /> 8022 A(1/97) / <br /> eToo—zz YELLOW: GENERATOR RETAINS INSTRUCTIONS ON THE BACK <br /> v. 9-88) Previous editions are obsolete. 1 <br /> 1 <br />