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arare ur s.wnormo—cnw/onmemar norecnon,.ngenry <br /> Form App roved OMB No.20504039(Expires 9-30-94) // � T See Instructions on back of 'lase 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pit, writer. y(�`��� Sacramento,California <br /> UNIFORM HAZARDOUS �enerator'slll US EPA ID No. Manifest Documer. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST 1, 1c of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number' <br /> 0`7 <br /> to 1, <br /> Union Ire CO. J <br /> nP.O. Box 108 B. State Generator's ID <br /> to 4t Generator�Phortet �)lE���' ..,..t t'oftn: Larry Iltsblort;ll - =� r,!,a't400 A <br /> p 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID <br /> O <br /> ao <br /> D. Transporter's Phone <br /> J <br /> Ericn Inc I-tIC7 <br /> J 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> Q <br /> U <br /> F. Transporter's Phone <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G, State Facility's ID <br /> a)z <br /> Q� 5. 1). 11YER5 <br /> MO 4425 SANTA FE DR. H. Facility's Phone <br /> Nv f<INCMAIV , AZ 66401A Z 1 - t 'd ? f60*21) 757 - 1 �t4 <br /> Q11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> Z No. Type Quantity Wt/Vol I. Waste Number <br /> Nz a. State <br /> (\j3 RQ , POI-.YCl-lLUF(lNATFD FQPFF� <br /> iFiJYL , 9, USI 231.5, r t <br /> III Elio tl 31 EPA/Other <br /> CN E ii <br /> co N b, State <br /> 00 E <br /> v R <br /> N EPA/Other <br /> v A <br /> pT C. State <br /> 00 O <br /> R EPA/Other <br /> w <br /> Z d. <br /> Z State <br /> LU <br /> U <br /> EPA/Other <br /> w <br /> 00 <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> 0 Ila . PCb CONTAII I NAI E D I I�AINISFORIIE:R +; 500 f-'f•PI Pl.i P' ��� a. b. <br /> } <br /> C. d. <br /> Zfir. r r.-'L ' <br /> 0 15. Special Handling Instructions and Additional Information <br /> t- 2a kilt. EI IEFi6j:f ICY CON T,Ac T' <br /> Q OUT OF SERVICE DATE: 0� ,/14/94 ( ,�,t d .�_� <br /> Z AVOID SKIN CONTACT, WEAR PROTECTIVE CLOTHING <br /> w 24 HR. E:ME14GENCY PHONE. <br /> t <br /> J f GEPIERAYOR'S CERTIFICATION: I herebyeacare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> Qpacked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> U <br /> _i 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 /> J 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 /> V) 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 /> CY waste management method that is available to me and that I can afford. <br /> 0 Printed/Typed Name Signature, •� / f Month Day .Year <br /> Z T 1 Trans orter 1 Ackn wled ement of Recei t of Materials ••---" <br /> W R <br /> Ur n Printe' /Typed Name Signature Month Day ,,,,Year <br /> w v <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W R <br /> U- T Printed/Typed Name Signatures Month Day Year <br /> O It <br /> w 19. Discrepancy Indication Space <br /> V) <br /> U F <br /> A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> DO NOTr RITE BELOW THIS LINE. <br /> Yellow: TSDF- SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (12/91) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br /> t <br />