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TEXAS NATURAL RESOURCE ori 7 -1.95-v1 <br /> CONSERVATION COMMISSION <br /> P.O. Box 13087 x <br /> Austin,Texas 78711-3087 r <br /> Please print or type.(Form designed far use on elite(12-pitch)typewriter.) Form approveJ.OMB No.20500039. <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No Manifest 2.Page 1 Information in the shaded areas <br /> WASTE MANIFEST 0Document,Nq; of is not required by Federal law. <br /> 3.Generator's Name and Mailing Address 1 O / <br /> BOX 6004 <br /> SAN RAMON CA 94583-0804 <br /> 4.Generator's Phone 209 1-78- 5555 : <br /> 5.Transporter 1 Company Name 6. US EPA ID Number ' <br /> SAFETY-VL.EEN SYSTEMS, INC TXR0000.50 . <br /> 7.Transporter 2 Company Name 8. US EPA ID Number <br /> 9.Designated Facility Name and Site Addres0006 I a 10. US EPA ID Number bl±1Fi•! <br /> SAFETY--KLM4 SYSTEMS, INC. # t1 <br /> 1721 COOPER CREEK ROAD <br /> DENTON, TX 76208 <br /> 7XD0776.03371 <br /> 11A, 11.US DOT Description(Including Proper Shipping Name,Hazard Class,ID 12 Containers tor. 14. <br /> HM Number and Packing Group) No. Type otal Unit <br /> quantity WVVol <br /> 9. <br /> WASTE SOLIDS CONTAINING FLAMMABLE. <br /> E X LIUri) N, O. S.. BENZENE, LrAi1) M <br /> N <br /> E b. <br /> R <br /> A <br /> T <br /> 0 <br /> R C. <br /> d. <br /> i <br /> 15.Special Handling Instructions and Additional Information MFST R/T#144831876 (1001-9977-14 <br /> EMERGENCY RESP 800-•468-1760WE14T 4 HR) Ir UNDELIVERABLE RETURN TO GENERATOR. <br /> SK CORP AUTH'D TO USE St1BSECARRIERS; 81300 4035-5, 4141°i, 40581, 54815 <br /> DOT A: 19006 6: C: D: <br /> 16 GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by:he proper shipping name and are <br /> classified.packed,marked,and labelled/placarded.and are in all respects In proper condition for transport by highway according to aFplicable internatlonal and national <br /> government regulations.including applicable state regulations. <br /> If I am a large quantly generator,I cerlify that I have a program In place to reduce the volume and toxicity of waste generated to tha degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,at disposal currently available to me which minimizes the present and <br /> future threat 10 human health and the environment:OR,If I am a small quantity generator.I have made a good faith effort to minimiz-f my waste generation and eeleCt <br /> the best waste management method that is available to me and Ihat I can afford. <br /> Printed/Typed Name.—_., Signature Month Day Year <br /> v r <br /> T 17.Transporter 1 Ackno .. <br /> wle ement of Receipt of Materials Date <br /> P Month Day Year <br /> A Printed/Typed Name Signature <br /> S ) p <br /> 0 1 B.Tra iter 2 Acknowledgement of Receipt of Materials �� Date <br /> la 5i nature Month Day Year <br /> T Printed/Typed Name 9 <br /> E <br /> Fl <br /> 19,Discrepancy Indication Space <br /> F <br /> A <br /> L 20.Facility Owner or Operator Certification of receipt of hazardous materials covered by III manifest except as noted in Item 19- <br /> T oats <br /> v <br /> PrintedrTyped Name Signature Month Day Year <br /> Tf+ff6� 1elv4�� 1)f>of 1 9 White-original Pink-TSD Facility yellow-Transporter Green-,generators first copy <br />