Laserfiche WebLink
Stale of Cal iforn o—Environmemol Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Deportment of Toxic Subslonces Control <br /> Please print or type Form designed for use on*lire(12 pitch) tier Sacramento California <br /> ' I Generator s US EPA ID No Manifest Document N 2 Page 1 Information in the shaded areas <br /> t UNIFORM HAZARDOUS <br />' WASTE MANIFEST ra �J C y, , - - ` �j' / 1 op <br /> snot required by Federal law <br /> 1 3 Generator s Name and Mailing Address Ny� �1A 'State Manifest Document NI%str A s <br /> B Stale Generator's ID ri i <br /> R + <br /> LO <br /> d Generator s Phone,�,J <br /> ! r s <br /> CN <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C State Transparler"s ID I ery ,„< <br /> co <br /> D Transporter',,PhOnp 8 <br /> 1 0 J:1 <br /> - <br /> cc <br /> 7 Transporter 2 Company Name 8 US EPA ID Number C State Tronsportert's ID&Lisry I ' f <br /> QF Transporter',Phone t g <br /> V 9 Designated Facility Nome and Site Address 10 US EPA ID Number G State Facility ID <br /> A 110101 4y�4 61 2 711 , 1111 <br /> !, i tif4J s <br />✓.�0 H Fact)'t�y's Phone <br /> p] y <br /> r <br /> J <br /> Q 12 Containers 13 Total I d Unit <br /> V 11 US DOT Description(encludmg Proper Shipping Name Hazard Class and ID Number) No Type euantity Wt/vol I Wat,lg Number <br /> SJ = o S <br /> 1,40t] 5X V <br /> , ra ,!. li.t�;JCi 10 1(V! `,I i Ir1l Jf)-) tale 223, <br /> EPA/Other <br /> E -1 A <br /> o N b State <br /> cc E <br />' v R EPA/Qther <br /> o T c State <br /> co O <br />' R EPA/Qtber <br /> Lj <br /> d Stole <br /> Z <br /> U EPA/Qt* <br />' J Additional Descriptions for Motarials Listed Above A p K Handling Codes for Wastes Listed Above <br /> OMY WATER <br /> a <br />' � a► Tom'T�n ti �1, n d s <br /> J <br /> 3 15 Special Handling instructions and Additional Information <br />' Z til _vc- <br /> ua <br /> Y <br /> i- <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the consents of this consignment are fully and accurate)y described above by proper shipping name and are clossiiied packed <br />' Q marked and lobeled and are in all respects in proper condition for transport by highway according to applicable internahonal and national government regulations <br /> v <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 determined to be economically <br /> a practicable and that I hove selected the practicable method of treatment storage or disposal currently available to me wh ch minimizes the present and future threat to human health <br /> end the environment OR if I am o small quantity generator I have made a good faith*{foil to minimize my waste generation and select the best waste management method that is <br />' ce available to me and that I can afford <br /> OPrinted/Typed Name Signature r-t t j j—if /s L-f ,? Month Day f Year <br /> , <br /> w 1 17 Trans otter 1 Acknowled ement of Racer Pt of Materials <br /> R <br /> L.0A Panted/Typed Nome r-f`"�/ / ,,/ Signature .(� Month Day Year <br /> P <br /> rl_ p 18 Trans orter 2 Acknowledgement of Receipt of Materials ` <br /> 0 1R Printed/Typed Nome Signature Month Day Year <br /> w E <br /> n R <br /> la1 19 Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> i <br /> 20 Facilrt Owner or O erator Certification of recer t of hazardous materials covered Icy this mqriifesi,axZept as noted in Item 19 <br /> T Printed/Typed ame Srnature on <br /> Y / �/ — -'"' g Month Da Year <br /> 17lei*t rrlr j, Lam• ✓/�. �r <br />' DO NOT WRITE BELOW THIS LINE <br /> TSCtics sr, i� ,3E, E4ATOR WITHIN 3G DAYS <br />' DTSC 8022A 11/99) G „_rak, s r c's osre for Ercn5r,or out of sr- <br /> EPA <br /> r_EPA 6700-22 c 'C' -> i --5, onJ send Io (,TSC wirh,n <br />