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c <br />c <br />c <br />L <br />L <br />C <br />L <br />C <br />C <br />U <br />C <br />C <br />LL <br />2 <br />a <br />L <br />v <br />a: <br />C. <br />LL <br />LL <br />ac <br />LLLL <br />LL <br />C <br />LL <br />Q <br />U <br />A <br />Slate of ColiFarnia Environmental Not Cho ge <br />form Approved OMB No. 2050-0039 (Expirei 9=304 <br />Please print or type. Form designed for use on elite ll <br />DO NOT WRITE BELOW THIS LINE. <br />DISC 0 (1/99) <br />EPA 87700-0-22 Green: TRANSPORTER RETAINS <br />_ ,....: ,.1 <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No r Ott, r MomFpst Document No , } <br />:Page 7t Informofipry ra,Fhe_s ailed griw <br />WASTE MANIFEST <br />�. <br />CAL 000 2 21947 <br />�, z, <br />'�' ' ` - it not required by federal <br />4 <br />of 1S <br />3. Generator's Name and Mailing Address <br />6 s; a o J AUSTIN -L N TLIRMINRL SV <br />A. State Manifest Document Number�y <br />DAVE !".Tit LOCK <br />�yir/ � �'" <br />n <br />it �s'.. i it t -115T CA 95215 <br />B. State Generator's ID <br />n <br />4. Generator's Phone I ,". 0 � ( �. 6 0 0 2 <br />N <br />r) <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved] <br />') <br />:i��^.'�Y'•'Y--::i.Es::: SYSTEMS INC. R Oa 7 15 <br />D. Transporter's Phone <br />_ <br />J <br />7. Transporter 2 Com an <br />P Company Name 8. US EPA ID Number <br />. <br />$t�t3r69--5840" <br />E. State Transporter's ID Reserved.] <br />J <br />1 <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address <br />9 ty 050 10. US EPA ID Number <br />G. State Foci li 's ID144 <br />J%LL..L4 (SAN VVZE ), I <br />9 A A 1 <br />1021 .BERRYr:uSA RDCAD059$94310 <br />H. Facility's Phone <br />_ <br />SA •I JC`E CA 95i33I I I I I I I I I I 1 1 <br />804 545-3358 <br />i <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />I. Waste Number <br />1-401N--RCR'A HAZARDOUS i4A.STE LIQUID <br />stare 222 <br />= <br />c.;T€,, T,4T.TE,T., SL Ui?%K(N0T DOT REGULATF,D) <br />TT <br />E <br />EPA/Other <br />G <br />-3d <br />E <br />1 <br />quo <br />J <br />N <br />b' <br />State <br />i E <br />J R <br />EPA/Other <br />r A <br />T <br />c <br />State <br />i O <br />R <br />EPA/Other <br />d. <br />State <br />, <br />EPA/Other <br />J. Additional Descriptions For Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />b. <br />p <br />C. <br />d. <br />1 <br />15. Special Handling Instructions and Additional Information <br />MFST R/T#101704867 0002-6933--98 <br />11ESP 800-468-1760 24 HR). IF UNDELIVERABLE RE:TUR14 TO GENERATO-R. <br />AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY. <br />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 />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />IfI 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 />practicable and that I have 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 />available to me and that I can afford. r <br />Printed/Typed Name i i <-Signature <br />7 1 .l •,- 1 <br />1 1 <br />/ <br />nth, <br />Ma / Dpy Year <br />i LL <br />R17. <br />Transporter I dcknowled ement of Receipt of Materials <br />A <br />Printed/Typed Name <br />Signature; �'' ^Month Day Y'1ear <br />n <br />f } <br />0 <br />18.' Transporter 2 Acknowle ement of Recei t of Materials <br />RPrinted/T <br />T <br />ed Name ignature <br />YP Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space � <br />F <br />A <br />C <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered b this rrranifesf except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature'` <br />Month Day Year <br />DO NOT WRITE BELOW THIS LINE. <br />DISC 0 (1/99) <br />EPA 87700-0-22 Green: TRANSPORTER RETAINS <br />