Laserfiche WebLink
State of Calrfamic—Environmental protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30.945) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Farm designed for use on aide(12-pitch)typewriter Sacramento California <br /> 1 Generator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> F3Generaftr <br /> IFORM HAZARDOUS Q is not required by Federal law <br /> WASTE MANIFEST j R ( �� :s of <br /> s Name and Mailing Address r' A State Manifest Document Number <br /> ,� A- c_o <br /> dr_, �- f -- 95228733 <br /> ��/j B State Generafors ID <br /> n 4 Generator's Phone" 1) 3 3s 07 t30 <br /> S Transporter 1 Company Name f 6 US EPA ID Number C State Tronsporter's ID <br /> D Transporters Phone <br /> C A T B G Q l 1 9 804 874-4444, <br /> Q7 Transporter 2 Company Name 8 US EPA ID Number E State Transporters ID <br /> J <br /> F Transporter's Phone <br /> Z 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Foctlty's ID <br /> 0 PAC PATTERSON t, 1NC. CAD 0 8 3 i & 6 ! 2 8 <br /> 13331 1,1. AIW--. 33 H Facility's Phone <br /> U PATTERSON. C.A. 95383 C A fn. O) 3 3 I b b 7 ? 3 800 A �S-�adi4h <br /> Z 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) N CoiHaino Ty 13 Total 14 Unit <br /> Quantity Wt/Vol I Waste Number <br /> ra state 223 <br /> EPA/Other <br /> o C4 G NON RCEttA iL4ZARDOUS ;ASTLE 341Q ID i; a ? i T <br /> OD N b Stall <br /> C R EPA/Other <br /> Tc state <br /> O <br /> R EPA/Other <br /> W <br /> Z d stoic <br /> LU <br /> U EPA/Other <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Lrded Above <br /> a b <br /> WATER & OIL 01 <br /> J c d <br /> a <br /> Z <br /> knIQ 15 Special Handling Instructions and Additional Information <br /> a .2.4 .lit. &NER r-NCY ZOINTAL"T: ?RC v i-(300)-874-4444 <br /> Z �u YR. D'ERGENCY ESPONSEs CH&I TEL INC. 41--(800)---55--3924 <br /> LU A?P�WPPiATE 1 CIT^CTIVE CLI)TfING ai US?1?.AT0R. <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 <br /> Vpacked 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 in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> a economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future <br /> threat to human health 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 <br /> waste management method that is available to me and that I can afford <br /> O Printed/Typed Nams� f .� r., 7 Signature J� f Month r T <br /> Z T 17 Transporter 1 Acknowledgement of Receipt of Materials <br />� A Pnnted,{Trp';d Name Signature �_ ✓^ �' �+Aonth.y r�Dcrt fYear-r- <br /> P <br />� O 1$ Transporter 2 Acknowledgement of Receipt of Materials <br /> U. 7 Printed/Typed Name Signature Month Day Year <br /> p E <br /> R <br /> W 19 Discrepancy Indication Space <br /> v7 <br /> a F <br /> U A <br /> Z C <br /> 1 <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A (9/94) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />