Laserfiche WebLink
E <br /> State of Cal Fornia—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Subslances Co, <br /> Please p-nt or type Form designed for use on elite 112 path)typewriter Sacramento California <br /> r UNIFORM HAZARDOUS 1 Genera Tor s US EPA ID No Manifest Document No _2 Page 1 Informait n in the shaded areas <br /> is not re uacd b federal law <br /> ' WASTE MANIFEST 4 ( of <br /> 3 Generator s Nome and Mailing Address D', C A State Manifest Document Number - <br /> ��� cu � y <br /> B State Generator s ID � <br /> 4 Generator s Phonea 17 <br /> CN 5 Transporter I Company Name 6 US EPA ID Number C State Transporterys ID[Reserved] � ` <br /> m D, Transporter's Phan r 1 } <br /> ao 7 Transporter Company Name B US EPA ID Number E State Traiisp`orter k ID[Reserve <br /> p Q F Transpoife/s Phone <br /> 9 Designated Facility Name and Site Address TO US EFA ID Number G State Fduhty s ID <br /> fM d R r,e1'r&112 <br /> LO ce / pci) / H' FhYs Phone+n' l� <br /> v cy, <br /> � <br /> ii J /�. 1 2 Containers 13 -r—ow 14 Unit <br /> 4 V U 4 616S <br /> 1 I US DOT Description(including Proper Skipping Name Hazard Class and ID Number) No Type Quonhty Wt/vol I Waste Number <br /> Z a �` ffy + State <br /> ze <br /> t- <br /> G EPA/Other <br /> r <br /> O N b Stale' <br /> ao <br /> co E <br /> EPA/Other <br /> 'Q R <br /> C14 A c Stale` <br /> Q T <br /> O° O <br /> R EPA/Other ' <br /> � <br /> w d State <br /> 1— <br /> W F <br /> V EPA/Other <br /> F <br /> 1J Additional Descriptions For Materials listed Above K Handling Codes for Wastes tilted Above <br /> LFl1 �. ". ` r' <br /> i a v r <br /> �+ _ c d <br /> 15pf�ecfHandglnsruch nsAdd di '1information <br /> C��v� / I � sfCJI TC7 <br /> 7 <br /> Lu <br /> .j 16 GENERATOR CERTIFICATION I hereb declare that the contents of this consignment are Full and accuralely described above by proper shipping name and are classified packed <br /> Marked and to eled and are m elf respects in proper condition for transport by highway according to applicable international and national government regulations <br /> V <br /> 2 IF 1 em a large quantify generator !certify that I have or program m place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> o- practicable and that t have selected the racticable method of treatment storage or disposal currently avodable,to me which minimizes the present and Future threat to human health <br /> vs <br /> and The envvonmen! OR if I am a sma I quantity generator f have made a go faith effort to minimize my waste generation and select the best waste management method that is <br /> Oavailable to me and that I can afford <br /> P ted/Typed Nome 5sKrtaiure } ' Month Day Yea. <br /> Wo T 17 Transporter tknowled ement of Receipt of Materials <br /> [ w Printed Name Signature /j Month Day Yea <br /> LU P t( i _ <br /> Li- 0 18 Transporter 2 Ac Howled a Ent of Receipt of Materials <br /> RT Printed/Typed Name Signature Month Day Yea <br /> t <br /> LLO E <br /> � s <br /> LI <br /> 19 Discrepancy Indication Space <br /> z F <br /> A <br /> _ C <br /> 20 Facile Owner or Operator Cerhftcat n of receipt of hazardous materials covered b this st exce oted in Item 19 <br /> j Prmted/Typ e\ Signature a Month Day Yea <br /> {/ / DO NOT Wi(ITE BELOW THIS LINE. <br /> I Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> 22A ll/99) (Generators who submit hazardous waste for transport out of state <br /> DTSC 80produce completed copy of this copy and send to DTSC within 30 days <br /> EPA 87022A ] <br />