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Form Appravvd OMS No.2050-0039(Expiry 9.3094) �V See Instructions an back of page 6. Deponrn.e of Toxic Subaawm CoMr< <br /> Plea -print or type. form designed for oto an okso(12pikhl t hr. Sacramento,California <br /> UNIFORM HAZARDOUS 1. ratoes US EPA ID No. Manifest Document fv� 2. Page 1 tnlormatran in the shaded areas <br /> WASTE MANIFEST � a M � se <br /> not rtrr.a by Fedoras la <br /> of <br /> 3. Generators Name and Mailing Address/1 0�1 <br /> in4. Generator's Phone ( 2 A CJ'10 4 <br /> d 5. Transporter 1 Company Naar 6. US EPA ID Number <br /> G 'ej4'V Z y 9 <br /> J <br /> —+ 7. Trantporter 2 Company Name 8. US EPA ID Number <br /> a <br /> U <br /> < 9. Designated Facility Name and Site Address 10. US EPA ID Number <br />�o Erickson, Ince <br /> TSS parr Blvd& <br /> Richmond, Car: 94901 ICAD 10 10 19141616 31912 <br /> 12. Contained. 13. Total 14, Unit <br /> 0Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type VAIVd <br /> N FE a. <br /> Waste Eapty Storage Task <br /> �3 G HON—RCRA Hazardous xaste Solids T P <br /> o E <br /> N b. <br /> Nt E <br /> C4 R <br /> A <br /> T C. <br /> O <br /> tY R <br /> d. <br /> W <br /> U <br /> W <br /> N <br /> 9Z <br /> 2 <br /> N <br /> W � <br /> OC <br /> J <br /> Z <br /> O 15. Special Handling Instructions and Addniaal Information <br /> a Keep away from sources of ignitions. Always wear hardhats when working around <br /> W U.SsTa l s 24 Mrs Contact !lame �.�a��^� �_. _ 6 phenol � ,,. � qLiq u <br /> S'�� <br /> LU *- <br /> t•- <br /> J 16. GENERATOR'S CERTIFICATION: t hereby declare that the comm t of the consignment are Puny and accurately described above by Proper shippksg tame and are classified, <br /> < packed,marked,and labeled,and are in oM respect%in proper condition for tronsport by highway«cording to applicable federal,state and W-nu"Oncl laws. <br /> U <br /> if 1 am a large quantity generator, I certify that I have a program in place to reduce the volume and b:icity of wast gesriated to the degree I have determined to be <br /> 'j economkolly practicable and that f hove selected the practicable method of treatmed,%toroge,or disposal currentfy avai to ere which minimises rho pressed and future <br /> sn <br /> threat to human health and the environment; en <br /> r OR,If I am a smquantity generator,I have node a good faith effort to minimize my vmde generation and select the best <br /> OC wade manogem9f1t method that is available to me and that 1 can afford. - .y <br /> O Prided/Typed None Modh Day Y <br /> rt,%.u< � 11.. L �,,,;.rte, 4 'L. sill . ', t7 2 t,, <br /> Z T 17. Tionsporw t Acknowled emed of Receipt of Motariak <br /> W Printed/Typed Name 11 Srpnoiu <br /> Uj P <br /> W � <br /> wi 18. Trom rter 2 Acknowled of Recce of Materials <br /> T Printed/Typed Name Signature Morels Day Year <br /> 0 <br /> N 19. Discrepancy Indication Space <br /> V A <br /> Z C <br /> 1 <br /> L <br /> I20. Fail' Owner or Qjttrotor Certification of receipt of hazardous materials covered by this manifest except as noted in Mem 19. <br /> T Printed/Typed Name Signature Modh Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS UNE. <br /> DTSC conA (12/91) <br /> EPA 87oo-22 Yeflown GENERATOR RETAINS <br />