Laserfiche WebLink
� uurai uru--urvrrumnrniw rro�ew�on r.yency <br /> Form Apt.-oved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control <br />' <br /> Please-print ror tyIV Form designed for use on elite 112 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS k Generator s US EPA ID No A-I Manifest Document No 2 Page 1 Information in tfie shaded areas <br /> WASTE MANIFEST snot required 6y federal law <br /> of <br />' 3 Generators Nome and Minting Address �r it !� k -T" A State Manifest ppcument Number <br /> err•r.r f-� C� (} �; '41576 2 <br /> B Slate Generator's ID ' <br /> 4 Generator s Plane (","� ) L)4 -/.( r-7 ) <br />' 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> O Ile <br /> 0. � 6_ 1 s. il d 'j D Transporters Phone "��tr� <br /> 7 Transporter Company Name 8 US EPA ID Number E State Transporter's ID(Reserved] I <br /> IJ <br /> J a F Transporter s Plane <br /> 9f Designated Facility Name and Site Address 10 US EPA ID Number G Stale Facility s ID <br /> ¢ t <br /> Q e_It firt rylE l•! B"� rt fit '" r'T ' — �.�or ! tom i, <br /> Z + 4 a,+ G (rk{,i; <br /> � �] ` H Facilitys Phone <br /> d rpt rl w� a �' o ' t ,} r f ,r'> , = CstEr -mss <br /> f f- ,, r <br /> U11 US DOT Description(including Proper Shipping Name Hazard Class and 1D Num6er) 12 Containers 13 Total 14 Unit <br /> FF � No Type Quant}ty W!/Vof I Waste Number <br /> Z a r f{1 f t1ti I f I lr+Fi F i r i -f{' i l� State 1 r <br /> 3 G t r r { r t ra t r + ! ! TIT <br /> , ] I s EPA/Other <br /> IC14 E Q N 6 i P <br /> State <br /> °D <br /> OD E <br /> R s EPA/Other t <br /> � A i <br /> 1� T <br /> State <br /> ado O r i <br /> R r EPA/Other <br /> d <br />' d State {i} <br /> Z � ' <br /> w <br /> () EPA/Other <br /> LU <br /> J Additional Descriptions for Materials listed Above K Handling Codes for Wastes listed Above <br /> w <br /> a d <br /> 15 Special Handling Instructions and Additional Infration a }� s -� }� <br /> Q ti�arfr~j jrSaJidr da�f <br /> wtCf/�rT L�3 4F i )ydta f '�Irr pi^i,ct� <br /> t-- <br /> -4 <br /> -4 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed <br /> a marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <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 economically <br /> n practicable and that I have1.11:1 selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment OR if I am a small quantity generator I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> 0 available to me and that I can afford <br /> }. PnntedlTyped Nom d 3 1 <br /> Signatures I !t i t Month pay Year <br /> 1-3 <br /> dd } f r _ <br /> Ur R 17 Trans arter 1 4cknowled ement of Receipt of Materials L <br /> LU N Prmted/,,Ped ame �f F � Signature .r �s { 1�' `Month ryDay Year <br /> Pe, 7 li'+, itr. ' <br /> 1U- <br /> 0 18 Transporter 2 Acknowled eme of Receipt of Materials <br /> TPrinted/Typed Name Signalure Month Day Year <br /> 4t 1 E <br /> R <br /> V� 19 Discrepancy Indication Space Z F <br /> A <br /> C <br /> I <br /> 1 20 Foci ityOwner or Opera—tor Certification of recei t of hazardous materials covered b this manifest except as noted in Item 19 <br /> T Prmted/Typed Name ! Signature i Fr Month Day Year <br /> rF"� i Y <br /> v f� <br /> IDO NOT WRITE BELOW THIS LINE <br /> Yellow 15DF 5ENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out of state <br /> EPA 8700-22 pioduce completed copy of this copy and send to DTSC within 30 days] <br /> r <br />