Laserfiche WebLink
State at Lolitornio—tnvironmenral rromcrlon Myepmy 1 <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of pc, 6 Department of Toxic Substances Contra <br /> ' Please print or type Form designed for use on elate(i2 Pilch)type Sacramento California <br /> UNIFORM HAZARDOUS 1 Generators US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> is not required by Federal low <br /> WASTE MANIFEST .f of <br /> s f <br /> 3 Generator s Name and Mailing Address A $tate Monifest Qocumerd Ngmibe7 s <br /> B State Generatdx:sLn <br /> fD "� i +� S " •n 5 0 <br /> 4 Generator s phone <br /> f 4i <br /> ' <br /> N5 Transporter I Company Name 6 US EPA ID Number C. Stow Traris"rtgr'sID[ft se" ' � ,' v ars <br /> in ' <br /> OD Trop po rterr s"1010 <br /> o � A <br /> a� 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's IP R s rved'] v tl <br /> � F TranfftaAsr(;�P♦�ong ` a ' � ri i <br /> q„t r V 9 Designated Facility Name and Sera Address 10 US EPA ID Number 0 Stats Facility's tD t" t> { �s <br /> ZH Facility s Phone <br /> Q12 Containers 13 Total 14 Unit <br /> V <br /> 11 US DOT Descnphon)including Proper Shipping Nome Hpzprd Class and ID Number) No Type Quantity W!/Vol I Waste Numbe4 <br /> Z a State <br /> 3 G f <br /> E <br /> I, <br /> o N00 <br /> a <br /> 00 E PI'A[¢tber I <br /> v R , <br /> A State + <br /> o T ` •_ <br /> O her <br /> op <br /> R <br /> c d State <br /> f <br /> I- 1 r <br /> EPA/Other <br /> V � <br /> w <br /> K Handit Cafes for Wastes Fisted Above <br /> J_Additional D@sc�iptions for Marerials,krsted Above 99 v r <br /> �+ryy i n b <br /> LU <br /> v T c a 11 is <br /> 1 <br /> a <br /> Q15 Spec iat Hendhng Instructions and Addsonal information <br /> Z <br /> 16 GENERATOR'S CERTIFICATION I hereby declare chat the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed <br /> Vmarked and labeled and are in all respects in proper condition for transport by highway according to applicable international and nattonol government regulations <br /> ' If I am a forge quantay generator I certify that I hove a prog <br /> CL practicable and that I have selectram in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically <br /> ed the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> 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 waste management method that is <br /> a available to me and shot I can afford <br /> OPanted/Typed Name Signature Month Day Year <br /> V y) a <br /> z <br /> T 17 Trans orter 1 Acknowledgement of Receipt of Materials <br /> RMonth Day Year <br /> tY A Panted/Typed Name Signature <br /> LL) R <br /> w P r <br /> U- p 18 Transporter 2 Acknawled amen)of Receipt of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> w E <br /> V) R <br /> V19 Discreponcy Indication Space <br /> F <br /> Z A <br /> C <br /> I <br /> L <br /> 120 Facility Owner or O eroior Cerhficatson of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T Prrnied/Typed Name Signalure Month Day Year <br /> Y <br /> r <br /> ' DO NOT WRITE BELOW THIS LINE. <br /> , <br /> DTSC 8022A 0/99) Yellow GENERATOR RETAINS <br /> ' EPA 8700-22 J- <br />