Laserfiche WebLink
late of California—Heallh and Welfare Aper <br /> ` Form Approved OMB No.2050--0039(Expit J-91) 0-� 0 l <br /> Please pri.., r, tYPe. (Form designed/d use un elite I2- (((Itch f Department of Hea• Se <br /> ( P typewriter). Toxic Substances C..---,j <br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Sacramer-_ Calr <br /> WASTE—MANIFEST - Manifest 2. Page 1 <br /> 0141 <br /> 4 8 6 2 8 0 7 7 Document No. Information in the shaded arrz s <br /> C, 0 of <br /> 3. Generator's Name ind Mailing Addrear\ is not required by Federal ia. <br /> �MN A. State Manifest Document Number <br /> 53�y0y•E�S�r��T�7 S`iR or 1 <br /> 4' >•flltlril`rTMQtO . 95202 B. State Generator's 10 --- <br /> O 5. Transporter 1 Company Name <br /> 8. US EPA li 10 Number C. Stats Transposer's 10 - <br /> 7. Transporter 2 Company Name 6 6 3 9 2 D. Iransporter's Phone — <br /> 41 ) 235-139; <br /> OO 8- US EPA ID Number E. State Tranaporter's ID <br /> ra <br /> 9. Designated Facility Name and Site AddressF. Transporter's Phone — <br /> QEP <br /> SCK.�N, 10. US EPA ID Number <br /> G. State Facility's 10 <br /> U 255 PARR BLVD <br /> RIC-kiUND, CA. 94801 H. Facility's Phone <br /> cr IC LA D009466392 (415) 235-1393 <br /> 11. US D07 Description(Including Proper Shipping Neme,Hazard Claes,and IO Number) 12. Containers 13. Total <br /> _j U <br /> U e' No. r Quantity <br /> Unit <br /> ype Waste <br /> WASTE, \/r�rrty Srpop7� r7 WVVoI <br /> _Z f•'xC'1.711i, 'iCli JLViIr' y�T�r.� Stint. <br /> CALIFORNIA <br /> 3I NWAS"1'E ONLY EPAlaser <br /> R 0 0 1 r <br /> o P ; <br /> to T P Abd <br /> State <br /> O <br /> C\1 R c, EPA/Omer <br /> g <br /> ao — <br /> Stale <br /> cc t <br /> EPA/Omer <br /> W d <br /> t- <br /> Z <br /> W State <br /> U <br /> w <br /> OJ. Additional Descriptions for Materials Listed Above EPA/Other <br /> a 1} Et�TY [Jj� pID K. Handling Codes for Wastes Listed Above <br /> U) I C>ASOLIN- TANK NO.�S z q b. <br /> ir ICS WITH 15 LBS. DRY ICE PER 1,000 GALLON D 1 <br /> CAPACITY S <br /> Z SCEHD tt C. d. <br /> 0 <br /> I5. Special Handling Inalructlons and Additional Information <br /> Z <br /> JAN 5 #?� <br /> ENVIRONIIPE_. <br /> 18. <br /> .� GENERATOR'S CERTIFICATION; 1 hereby declare that the contents of this consignment are fully and accurately described above b <br /> and are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according <br /> N national government regulations. Y proper ternahg-arae <br /> to aon!ir_sble i^teraat,cna�a-- <br /> national <br /> It i am.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 deter- <br /> O to be economically practicable and that I have selected the practicable method of treatment, storage,or disposal currently available to me which mmim,es -- <br /> y present and future threat to human health and the environment.OR,if I am a small quantity <br /> U generation and select the best waste management method that is available to me and that Igcan afford. nava made a <br /> Z good faith effort to minimize my was•- <br /> LU Printed/Typed Name <br /> O <br /> a: Signa ure <br /> w I L 0, C L Ya Y To ,-) / Mgnfh Ce. <br /> W R 17. Transposer I Acknowledgement of Receipt of Materials <br /> < NA Panted/Typed Name <br /> /7 <br /> u_ S <br /> OP a,/T�t/ Month D •-a <br /> N O IB. Transposer 2 Acknowledgement of Receipt of Materials �".-�` <br /> Q R Printed/Typed Name <br /> V <br /> U E Signature <br /> Z Monts Da. <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or O <br /> T perator Certifcation of receipt of hazardous materials covered <br /> y Print ped Name s manifest except a noted <br /> T <br /> Signatur <br /> Df IS 8022 A(t/88) Q/✓7.+r�d^ I /I / L <br /> 0-- <br /> EPA 87022 Do Not Wr ow This line •S�.! <br /> (Rev-9-88)Previous editions are obsolete. LV <br />