Laserfiche WebLink
j <br /> Stole of California—Environmenlat Protection Agency ql <br /> Form Approved OMB No.2050-0039(Expires 9.30-96) See Instructions on back of page 6. Department of Toxic Substances Control <br /> Please print or type. form designed for use on elite(12-pitch)typewriter. Socramenlo,Calllornia <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST of i <br /> 3. Generalor's Name and Mailing Address ;&M�StateManlfest4Documenl�Nvmbq� <br /> --' ° •� 'B;State Generator c ID "^�g¢�' � <br /> (Vr ;g <br /> LO 4, Generator's Phone ( ) _ W 8 y y ''#J 11 <br /> } ,, •! <br /> <5 5. Transporter I Company Name 6. US EPA ID Number C StateTransporter ID { 71 <br /> O 1 rr i <br /> 09 _d t.: t!I 1 <br /> Ci A `� J 1} <br /> J <br /> 7. Transporler 2 Company Nome 8. US EPA IU Number E;.Slate7ra,flis r1411-'1-;.- <br /> 9.,Designated <br /> ID 9.,Designated Facility Name and Site Address 10. US EPA ID Number <br /> i <br /> 01 <br /> 3 = d <br /> 1 s s n acrllty i of1� s <br /> LO <br /> ,j p a r <br /> sa l Q c�... .,i., wr t t , i•: ie +j f ,! 7j 4� :+ /� 'f ii _ix <- `.'fi' .1;''' a. _ qq <br /> w. . <br /> 00 V 12. Containers 13. Total 14. Unit <br /> ��y 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) i <br /> �J Z No. Type Quantity WI/Vol <br /> a. <br /> 3 ii ss "t"A �[ T t <br /> tV 1,..i'f','1,r s'i1s�7�. .]1 i1�'$.Iu Yr'1"i.i1C:r d( Lri! L7 i f 11 +A <br /> n E <br /> coo N b :. <br /> Co <br /> r g `.. <br /> A <br /> Tco <br /> c. 9 <br /> O <br /> R <br /> LU <br /> Z d• e <br /> LU <br /> V , <br /> w <br /> �gddit t[al_Descnptbnt for aiprlals llste Abo o ii g Cod 1"o a3k SIJ I <br /> !`t„` ,fixq' N p 3 �t�� `""fF, T'A�'C ?�. C SSP �,. -'i j r��f •a qV .L 3 <br /> t30 t; <br /> i <br /> O 15,-5pscial Handling Inslructions and Additional information r <br /> 1 <br /> LU <br /> WEAI3��U1',4t•!'SSk��`'',H,VI�S�f!�l9lt�lk�-,.: . , - - <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 /> Q 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 /> U <br /> 1 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 /> economically practicable and that I have selected the proclicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> CIL <br /> cn threat to human health and the environments OR, it 1 am a small quantity generator, I have made a good failh:efforf to minimize my waste generation and select the best <br /> ex waste management method that is available to me and that I can afford, <br /> O / yp ( �/ Signature ' Jam%' • f Month Day Year <br /> Printed T ed Name � /r rr r"� � <br /> r f,, r, .�: . , -• :r". u.�'_- :;-mss <br /> Z <br /> T 17. Trons orler 1 Acknowledgement of Receipt of Materials <br /> (� It <br /> A Printed/Typed Nome Signature Month Day Year <br /> R ;f <br /> w <br /> P <br /> LU a 18. Transporter 2 Acknowled emenl of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> LL T <br /> O E <br /> R <br /> N 19. Discrepancy Indication Space t <br /> U F <br /> A <br /> Z C <br /> I <br /> l <br /> 1 20. Facili Owner or O erator Certification of recei t of hazardous materials covered b this manifest except as noted in Item 19. <br /> Signature Month Day Year <br /> )T Printed/Typed Name <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DT5C 8022A (1/95) Yellow; GENERATOR RETAINS <br /> EPA 8700-22 <br />