Laserfiche WebLink
State of Caldormo--Emtronmental Protection Agency <br /> Form Approved OMB No 2030-0039(E�pires 9-3696) See Instructions on back of page 6 j // /' Deportmem of Toxic Substances Control <br /> Please print or type Form designed for use on elft(12-pfhh)typewriter � ! Sacramento California <br /> UNIFORM HAZARDOUS 1 Generators US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST ! (� Uh 4/ /� of ! is not required by Federal ksw <br /> . 3 Geoer rs and M h Address' - 4 J jl pl s <br /> ,Vtr T1fd!C r/ <br /> nOD <br /> 2 <br /> 4 Generator's Phone j & , 17'� <br /> 5 Transporter I Company Name 6 US EPA ID Number s <br /> J <br /> C � l iron -1,7 C IC 0 1,0 12, <br /> Q7 Transporter 2 Company Name S US EPA ID Number <br /> U <br /> a <br /> Z 9 Dmggnpled�gal;f,N w and Site Address 10 US EPA ID Number <br /> rC...��.Ai�C.tr';+ TT1l �1 EEII ? <br /> O 2 5 5 Parr E?v'J , <br /> r Q F<1C-t�ndrC �4 f)� �` A t%�°� C1 9 4 6 3 9 a � <br /> cc <br /> 11 US DOT Description(including Ploper Shipping Nome Hazard Class and ID Number) 12 Containers 13 Total 14 Unit <br /> Z No Type Quantity Wt/Vol <br /> L- ONCZt-�'RA HazazdcxAs Waste -':;o1:03 <br /> N G Waste Empty 51 -rcu.Te Tam � ,1 T ,� c� C t3 r <br /> O E <br /> CO N b <br /> CIO <br /> v E <br /> v <br /> R <br /> T c <br /> 0 <br /> R <br /> Uj <br /> Z d Stale. <br /> LU U� <br /> U <br /> FFA/Ot <br /> arwt <br /> J 1tddltfott;ttri6Ts llsted Abe" K ffandl"mg Codes for Wastes ltsied Alsovs <br /> LU Qtly.Des' tlortF for MateStorage r�r f b <br /> Q <br /> itismy ice Pw boo W104 ovwity. p` t d. <br /> Z <br /> O 15 Special Handling Instructions and Additional Information <br /> a Kt=er awey from, 30urCes ,-)f tz�i•Yx� Plw�w x '�a 3l:r-,t ; 1��i ti4� air T �s �>zuk i <br /> Z �r l .�. r, �� E1 7fcsC i'uctfT'>� 'rf. '� . �ll� +�, _ 12{?ti '� =`_i _� -.J 1 <br /> ssa S <br /> ;r{ <br /> J 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 /> J <br /> 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 /> - If I am a lar(je 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 <br /> a econom�colly prochcable and that Ijlpve selected the practicable method of treatment storage or disposal currentlyci able to,age which minimizes the present and future <br /> in threat to human health and the vii OR d I am a small quantify generator I have made a good faith effd"mmimae'my waste generation and select the best <br /> waste mE22R=ent method that is available to me and that I can afford <br /> O Premed/Typed Name Signature T Month par Yea/ <br /> Z 1 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> its 11 <br /> (� N Printed/Typed Name r t Signature f Month Day gyeor, <br /> eil-e ,/ loir 7 <br /> iss R 18 Trans r 2 Acknowled emnt eof Receipt of Mate <br /> aL 1 Prtnted/Typed Name Signature Month Day Year <br /> O E <br /> A <br /> N19 Discrepancy Indication space <br /> Q F <br /> V A <br /> Z C <br /> I <br /> L <br /> I -Z9--E--j-1dY Owner or Operator Certificahon of rete' of hazardous materials covered by is manifest except as noted in Item 19 <br /> YPn /Typed NameSigrwhrre Morrlh! pay f �Year <br /> DO NOT WRITE BELOW THIS LINE <br /> Yellow TSOF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC BD22A (1/95) (Generators who submit hazardous waste for transport out of state <br /> EPA 87OD-22 produce completed copy of this copy and send to DTSC within 30 days) <br />