Laserfiche WebLink
arm Approved OMB No 2050-0039{Expires 9 30 991 See Instructions on back of --qe 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on ehte(12 pitch es tiler Sacramento,California <br />' UNIFORM HAZARDOUS i ®nerator's US EPA ID No Manifest Document No 2 Page 1 Information to the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST " ti r of <br /> 3 Generator t Name and Mailing Address A Stake Manifest Document Number r� r� <br /> I 1 3 77 [5'90 '1 <br /> B State Generator s ID <br /> 4 Generator s Phone I <br /> 'C� 5 Tronsporieri 1 Company Name 6 US EPA ID Number C State Transporter s ID]Reserved] <br /> + }�E �'s' r / r r �s p TranspA er s P e <br /> / t L r d ! I 4r :C' �.i <br /> 7 Transporter 2 Company Name B US EPA ID Number E State Transporter s ID[Reserved] <br /> J <br />( Q F Transporter s Phone <br /> V 9 Derr ed Fac f rid Silo drills 10 US EPA ID Number G State F cil s to <br /> gfq] .t iltyggela�, t] �q i rn S <br /> Q t <br /> t/ t 7�,1 ht it P> rlr r.Erl <br /> go <br /> H Facility s Phone <br /> 1 tt,'irlril7 s FI ( 1 t� l +ty tE tf i ! <br /> W <br /> J <br /> Q 11 US DOT Description(including 12 Coniumers 13 Total 14 Unit <br /> clud+ng Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> ' a <br /> 11 r+i I{ s tia'.ii+Tr's1 3� .r r, it <br /> p State <br /> S.{1 <br /> G 1 t) t t) EPA/Other <br /> ' E b State <br /> J <br /> EPA/Other <br /> 1 c <br /> Stale <br /> EPA/Other <br /> d State <br /> EPA/Other <br /> J Additional Descriptions For Materials Listed Above K Handling Codes for Wastes Listed Above <br /> it ,ti 4' r� ;r',t( I' (F'° +[r 'rr :F ..i r ' ii r a b <br /> c d <br /> 15 Special Handling Instructions and Additional Information <br /> i'tow i a rats 's i'wditrra <br /> ] ` ] i i , t rr 'q , �'ius f i r,kill 4`'"ri Z 7f 0 1 <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are Fully and accuraiely described above by proper shipping name and are classified packed, <br /> marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations <br /> If 1 am a large quanhy 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 ecanomica11y <br /> ' practicable and that I have selected the rachcable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human heabh <br /> and the environment,OR if I am a small quantity generator I have mode a good Faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I con afford <br /> Printed/Typed Name ry Signature r j w Month Day Year V <br /> y✓e <br /> 17 Transporter I Acknowledgement of Receipt of Materials <br /> Printed/Typed Name Signature f N f` Month Day Year <br /> r�f1,3r,y r ��lx L it 1/r r. �� - - rt f r t( �� r/ l'! <br /> ' 9 Transporter 2 Acknowledgement of Receipt of Materials ' <br /> rated/Typed Name Signature Month Day Year <br /> Discrepancy Indication Space <br /> h Owner or Operator Certihcohon of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> ' Yellow GENERATOR RETAINS <br />