Laserfiche WebLink
I State of COW mq—Environmental Protection Agency <br /> II Form Ppproveu CsyB No 2050-0039(Expires 9 30 99) See Instructions on back of page <br /> Please print or P 9 Department of Toxic Substances C <br /> P type Form designed for use on elite(12 pitch)typewriter Sacramento California <br /> I r <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Informah in the shaded areas <br /> WASTE MANIFEST3�y is no!required by Federal low <br /> 1 fj _ ti I of <br /> 3 Generator s Name and Maihng Address �' A State Manifest Document Number <br /> 2453322 <br /> B State Generator s ID <br /> h 4 Generators Phone <br /> 30[ n 5 Transporter 1 Company Nome 6 US EPA ID Number <br /> L c in C State Transporter s ID[Reserved] <br /> Y ` D Transporter s PhoneCD <br /> _ <br /> �� 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID eserved <br /> Npa <br /> k 4v I I F Transporter s Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s ID <br /> (y�r19m f( rte! f T vAs { <br /> LoIx <br /> Z f <br /> t '�'� �f{�fVjT H Facility Phone <br /> ry�ryp� 7 L- = o lid <br /> `4V I 1 US DOT Descrrptron(including Proper Shipping Name Hazard Class and ID Number) IN <br /> tainers 13 Tool I4 Unit <br /> Z0 <br /> o T pe Quantity Wt/Vol I Waste Number <br /> '6011 [�:f7a" '!' k/ir"i-� -ffvt e'/ State t <br /> 3 E LCI I�s r f� EPA/Other f- ; <br /> o N b V State <br /> co E <br /> N R EPA/Other <br /> v A <br /> o <br /> Ts <br /> tate <br /> Q <br /> 5rare <br /> R EPA/Other <br /> ckc <br /> Z d <br /> Z <br /> Sfate <br /> n <br /> Lu <br /> t � <br /> EPA/Other <br /> i J Additional DeS <br /> } crtpdn <br /> ons for Maheolrs Listed Above K Handling Codes(or <br /> ?Wastes ii sled Above <br /> CL * a r` 6 <br /> to <br /> f <br /> ce <br /> � t <br /> i c d <br /> QF126 W <br /> Q15 Special Handling Instruct ons and Additional Information <br /> ~ , Lr "Cf7 <br /> { Q 16 GENERATOR 9 CERTIFt ATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classrhed packed <br /> marked and labeled and are in all respects m proper condition for transport y highway according to applicable international and national government regulations <br /> J_ <br /> If!am a large quantity generator I certify that 1 have o program in place to reduce the volume and roxiay of waste generated ro the degree I have determined to be economical)y <br /> tan <br /> practicable and that I have selected the racticabla method of treatment storage or disposal currently available to me which mimmrzes the present and future threat to human health <br /> and the environment OR it I am a smo I quantity generotor I have made v ood faith effort to minimize my waste generation and select the best waste management method that is <br /> I available to me and that I can afford '"'T <br /> 1 <br /> � PJrtwd�Typed Name �� ignarurelt �J Month Day Year <br /> ILI <br /> S Ur T 17 Trans atter owled empnt of Receipt of Materials �--- <br /> tA Printed/Ty d ome Signature JI /' Month Day Yeak <br /> M # t / <br /> W s !, Lf <br /> i O Q 18 Transporter 2 Acknowled ment of Receipt of Materials <br /> T <br /> Prmted/Typed Name <br /> Signature <br /> LU Month Day Year <br /> N R <br /> a <br /> C) F 19 Discrepancy Indication Space <br /> Z A <br /> k C <br /> 1 <br /> I y <br /> 1 20 Tacili Owner or O erator Certihcatio of recer t of hazardous materials covered b this manifest exce t as noted in Item 19 <br /> T Printed/Typed Nartfe"'3 �r / Signpture +^�7 - Month Day Year <br /> DO NOT WRIT BELOW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC 8022A (1/99) (Generators who submit hazardous waste For tronsport out of state <br /> EPA 8700-22 produce completed copy of This copy and send to DTSC within 30 days J <br />