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OF"W001 Protection Agency <br /> OMB No 2050-110 9 s 9 y See Instructions on back of page 6. D parm,.r of Tac subdonces cwool <br /> type Forrn for u,.as.M.{12�Nd1)srwwrrlrr socram.rNo California <br /> 1 Gsteraro/s US EPA ID No D�vortent No 2 Page I Infornwtan in the shaded areas k' <br /> UNIFORM HAZARDOUS is not rewired by F�edetoi lair <br /> WASTE MANIFEST /� 9 8 I 7 7 ' v� 7 ,� of f <br /> s Nome and Mmlrq Address <br /> 93?-SV 737 . /Af <br /> n <br /> Gee�. ( ) Z f <br /> 'f w ;etl A337tv <br /> S Transporter 1 Company Name 6 US EPA ID Number <br /> goo All11'912 <br /> Transporter 2 Compcpf Name S US EPA ID Number <br /> Djal4didy Nogg and 5th Address 10 US EPA ID Number. <br /> 255 Pair Blwi ' I <br /> RiCtllrOtld,244801 <br /> I US DOT Description(mciodmq Proper Shipping Name Hazard Clens and ID NN <br /> umber) N Corrtar o Type 13 Total It Ute► <br /> CuartAlr Wf/Yol <br /> a NON-'?CRA Hazardous Waste olid <br /> Waste Ehwty Storcwe TalnJe f 0,9,94. • 2 TI O 2 S 1010 <br /> p <br /> b <br /> c <br /> d <br /> FN <br /> "^4 r <br /> 13 Speaal Hondlmq Instrucfians and. information Y <br /> ;peep mw, fr,_)m sources ct i miti wav s wew <br /> wear hardhits het!: worklna ar-urvi t <br /> 1 r, T ' 24 Hr �_ctitact l`im#-_ ¢ P1itme r4 <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shopping name and am cioodned <br /> packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> If I am a large quantity generator I certify that I have a program on place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have seiected the practicable method bf�,tmatment storage or daposal currently available to me which minimizes the present and future <br /> threat to human health and the environment OR of I am a small npndffW 9"rator I have made a good forth effort to mmrmnze my waste generahon and select rhe best <br /> I \ <br /> waste management method that is avertable to me aril that I can afford <br /> r�ah�r� <br /> ^O. <br /> Plthrled/Typed Name Sr' Y _ j Mon-7 1- IN 1",_<, - 1:11 �tthh Day Year <br /> 71 71 <br /> 17 Transporw 1 Acknowleciement of Receie of Materials <br /> Printed/Typed Nanta jSnaturo Month Day Year { <br /> 1 <br /> I Tram r 2 Acknowledgement of e, t of Material <br /> Printed/Typed Name Signature Month Day Year <br /> 19 Discrepancy indication Space <br /> {r <br /> I <br /> 2 Focd Owner Or or O rator Certification of rata of hazardous matenols covered b this manifest ext as noted in kern 19 <br /> /Typed Name StgnaWm Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> U2A 11/931 Yellow GENERATOR RETAINS <br /> 22 <br />