Laserfiche WebLink
s <br /> Pieria print or type {Form oemoned for use on @lore 112 prrchi rypewnrer) Form Approved OMB No 2050-=9 Erptres 9-30.88 <br /> UNIFORM HAZARDOUS I Generator s US EPA ID No Mani let 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST D 9 B 1 1 18151 0 Docu�1 31 5 No of Yn not required by Federal law <br /> v Q <br /> 3 Generators Name and Mailing Address <br /> Wickland Properties (Regal 604 ) <br /> P-0. Box 13648 , Sacramento, CA 95853-4648 IL stater, <br /> A Generator 9 Phone; 916 I 921 -1100 (24 hours ) HYH � 4 • <br /> 5 Transporter t om�a—npy Name_ pUS EPA ID Number C state �i13 <br /> JJL <br /> 7 O T Phw1a •• •• <br /> 7 Transporter 2 Company Narnb, a US EPA lD Number E State Ttarta s 1 <br /> F T rte�e- <br /> 9 Designated acility Name and Site Address 10 US EPA ID Number M State Facluws it) <br /> H FZ�� <br /> hom <br /> w1A D o,of I 7 17 .2 - 6c�s <br /> 11 US DOT Description (including Proper Shipping 12 Containers of 14 <br /> p f q pprng Name Hazard Class and 1D Number) Total Unit Waste No <br /> 1 Na Type Quantity tivol <br /> C a Hazardous waste Solid lb �JCO2 <br /> PA <br /> N IV.O.S. OR{�lE NA 91 89 D z+7 Lel C <br /> lb <br /> E <br /> R b State <br /> T 352 <br /> o I I I <br /> R <br /> C <br /> I <br /> d ~� <br /> J Additional 0e3criptians for Materials Listed Above K� Handt"Codes for Wastes Listed Above <br /> ; Spent carbon canisters used fox- vapor e3€tracti6n wells <br /> l contaminated with unleaded fuels. Emergency contact <br /> George Converse (916) 334-0162/(9T6) 668-530a (24-hours) ry <br /> Acceptance #, 10-286-C <br /> 4�R <br /> 15 Special Handling Instructions and Additional Information <br /> Standard for petroleum range hydrocarbons <br /> 16 GENERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descrit>ed above by proper shipping <br /> name and are classified packed marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> 1 international and national government regulations <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 <br /> determined to be economically Dracticable and that I have selected the practicable method of treatment storage or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environment OR it I am a small quantity generator I have made a good <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford <br /> Printed/Typed Name agent for Wickland SigItwe i; Month Day Year <br /> George L. Converse 101 71 01 21 92 <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials J <br /> A PnntedtTypid Name Signature Month Day Year <br /> N <br /> az <br /> r <br /> 0 18 Tra rter 2 Acknowledgement of Receipt of Materials ^ <br /> R <br /> T P nted peName Signatu w C Month Day Year <br /> 19 Discrepancy indication Space <br /> f t <br /> A <br /> C <br /> t <br /> L <br /> 1 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by thisajanifesl except as noted in item 19 <br /> T PnntedrTyped Name Signature Month Day Year <br /> r <br /> r <br /> EPA Form 87DO-22 (Rev 9 86) Previous editions are obsolete Reorder No 860 Lab Safety Supply Co <br /> ORIGINAL-RETURN TO GENERATOR <br />