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State of Colifornio—Environmental Protection Agency131092 <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) eb. C m Structions on back O e 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch)*rifer. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> .WASTE MANIFEST P, P P R 4 16 14 12 19 10 11 5 18 10 2 .1of 2 <br /> JJ3. nerator's Name and Mailing Address0. �,fit, �+y y, q��t}, •3+gwC�tptp �lqr �.�qaV Gen !bR' 9a2 2Nd9 3:�3--3��Q wf � ARr�FL°� r.! �.'a Mme, is �$�"�` ��.i��j�"'�.�'� �': �...a �,ra� �.z,,.x�•�j„� <br /> 4. Generator's Phone ( ) <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number Tkff@ a = <br /> CP� N & ROGERS INC <br /> ICIAIDIOIIIO19121 151716 <br /> C? 7. Transporter 2 Company Name 8. US EPA ID NumberttteFtrLbi <br /> AN RMRS & ROGZRS INC <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Numbert afeutu sap �” yt kr } 1 <br /> z PO BOX, 11 � � r <br /> 9',OIJTR COY. ROAD <br /> tl �.i"3iafiPi Y F� <br /> YMMIA., YD'S 66136 IK IS I Ta 1918 1016 13 13 12 <br /> g Q <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12 Containers 13 Total 14 Unit1 <br /> ;/$U No. Type Quantity wt/vol <br /> 3, C12263, PQ 11, (RQ-100), (EPA P005 0001 D035), <br /> 3 G (ERG 127) DIM <br /> MINT LTERIAL <br /> o N 3 b 1253, 11, (RQ-100), (EPA x°003 D001), � <br /> 00 R (� G 1.27) ) <br /> -4 DIM , t7 <br /> 6 T c. <br /> w R <br /> LU d. <br /> LU <br /> LU <br /> 7$ w <br /> 15. Special Handling Instructions and Additional Information VIRAR APMPMTS PRMCTIW GEAR TAMMING. <br /> SHERMNCY CMTP=: C« 1-800-424 -9300. CALLER MUST IMMIFY VAN WATERS � <br /> Z <br /> ROGERS AS 5=PPZR. <br /> = 11Af VA38533, M. GA10733-VA02 <br /> 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,packed, <br /> V. 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 large 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 economically <br /> n practicable and that I hove selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N p <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 /> ao me <br /> available tand that I can afford. <br /> O .. e <br /> Printed/. ecl Name :_7 Si rf'ture a it >-"' Month Day Year <br /> y^�� <br /> Z <br /> .w�' <br /> 0 ./ <br /> T 17. Trans orter 1 Acknowledgement of Receipt of Materials <br /> (U <br /> ac R <br /> N R'nt d/'(ped an ^ p p !f Signa' q Month Day Year <br /> LU <br /> Uj <br /> U 0 18. Transporter 2 Acknowledgement of Receipt of Materials �' d <br /> O T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> N R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered 6 this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />