COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

State of California—Environmental Protection Agency Form Approved OMB No.2050-0039(Expires 9-30-9 ) See Instructions on back OF •e 6. Department of Toxic Substances Control Please print or type.' Form designed for use on elite f 2-pitch) ;ter. ;.... �-'`�' Sacramento,California UNIFORM HAZARDOUS :rator'sUS EPA ID No. Manifest Document No. - 2. Page 1~ Information in the shaded areas is not required by Federal law. WASTE MANIFEST of 3. Generators Name and Mailing Addresi A. State Manifest Document Number 751U- 1-,1-77� +.: 7^"ra.+ vt'�'s<'-s }•4i'r._. .._.. ._ .-..t*;' '�..` r,.'Cc. t�t��3,sT;'dtr' _J ,� ts'� .. ' u O :-. k 7a 115y s, B. State Generator's ID LO A. Generator's Phone (.- .i- I -?s• .t-.. s,r ��E N N 5. Transporter I Company.N'me 6. US EPA ID Number C. State Transporter's ID[Reserved.) OD b ., tt�.. ..��'S'. i'.''T�jmSs'e%Yd,. ,� D. Transporter's Phone w. 7. Transporter 2 Company N u y [ - � - O. _ _ . . p p y "I B. US EPA ID Number E. State Transporter's ID[Reserved.] Q ` '1. ` ,� t ( e .�) „ ,✓, _ F. Transporter's Phone A.a t U 9. DesidnaStecl-FisciliiiNamZ44 pd Site Addr 3ss 10. US EPA ID Number G. State Facility's ID r ..p, ''c•" ,i: Z ..L'` _.', H. Facility's Phone +d�}I 0 F: A. _ _7 J 12. Containers 13. Total 14. Unit 11. US DOT Descriptio'n'(inclui ling Proper$iipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/vol I. Waste Number Z a.WA-m-,-_ - Axr � x y . State ? s;7 G EPA/Other b. State o N- aa � »A�trr t+taa'„e 000o E I. L caasiv �? . 2_ T�D1351.3; e}01'," 3-4 Ri�3�' EPA/other o T C..i t9rs.'hX'+_r OUS 71 s� a +�eT_._. . .. . •:i 'T x''Ile `!Ir State _ R _ EPA/Other FW- d. .._ . . .. State or, W U EPA/Other LU V) J. Additional Descriptions for Materials Listei I Above K. Handling Codes for Wastes Listed Above O ? _ a. b. LU C. d. - J Q Z 15. Special Handling Instructions and Additional Information Z ":�.3k'f< 't3 'x +<"ON47.4"T: ;>3 b) 746-7449-” W t- 16. GENERATOR'S CERTIFICATION: I hereb e declare that the contents of this consignment are fully and accurately described above by proper shiping name and are classified,packed, (ail marked,and labeled,and are in all resf ects in proper condition for transport by highway according to applicable international and nationaPgovernment regulations. J If I am a large quantity generator,I cer ify that I have a program in place to,reduce the volume and toxicity of waste generated to the degree I have determined to be economica[Iy a practicable and that I have selected the racticable method of treatment;storage,or disposal currently available to me which minimizes the present and future threat to human health N and the environment;OR,if I am a sma I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is a available to me and that I can afford. 0 Printed/Typed Name, Signature~ Month Day Year Z �>, ! -,, 0 T 17. Trans orter 1 Acknowledgisment of Receipt of Materials - L,f uA, Printed/Typed Nome Signature �i Month Day Year i _ 17 yy / LU $ �3 ~3', ✓ f ,� !.✓":�° ?�,,9 til✓ " I � y� _._._.. �' W% u:. p 18. Transporter 2 Acknowledgement of Receipt of Materials " O T Printed/Typed Name , Signature Month Day Year --- Uj U 19. Discrepancy Indication Space Z IF A C - L f 20. FacilityOwner or Operator Certification f receipt of hazardous materials covered b this manifest except as noted in Item 19. RECENEY- T Printed/Typed Name Signature Month Day Year S DO NOT WRITE BELOW THIS LINE. APR 8 o 2002 Yellow: TSDF SENDS THIS-COPY TO GENERATOR WITHIN 30 DAYS. DTSG 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) BEVERLY ROSE