Laserfiche WebLink
I <br />State of Ccltifornia—Environmental Protection Agency <br />;arm Apeovecl OMB No. 2050-0039 (Expires 9-30-991 <br />Form desig4ad for use on elite, (fg-pikh) tftjffi & 2 20040 Instructions on back e 6. Department of Toxic Substances Control <br />r 009 <br />ia �01 jypp. F <br />,,A 4 <br />HAZARD <br />1. nerator's US EPA ID No. Manifest Document No. <br />2. Page I Information in the shaded areas <br />WASTE �ANIFEST <br />01 �>i I q I <br />is not required by Federal law. <br />of I <br />V Generator's Name and Maili' g Add <br />V 1104 1' ./ -% jr leX <br />. <br />�kl <br />A. State Manifest Document m, <br />B. State Generator's ID 4 "wMi <br />.4,9. n <br />is erator's Phone 44 <br />V <br />S.',%Transporter I Company N&me 6 US EPA 11*1-6.r <br />C. State Transporter's ID [Rose <br />0 <br />AIR0111111M Sam <br />D. Transporter's Phone� <br />D <br />A 10 1� IS 1214 11 13121612 <br />Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID IRbLdryed I' <br />6 VIL V- b6i 41 P1 ,13 1( 1,31ZI I?- I'S J1 <br />(Arx <br />F. Transporter's Phone <br />J' 1 <br />�� -,rDe$iqnated Facility Name and Site Address 10. US EPA ID NuGn <br />�kowlq <br />SfbW`F6Cj ityYs 1D-7- <br />Ic A <br />1021H Olow <br />ROW <br />10 10 is I's <br />Facility's Phone <br />IC A ID IV ILA 14 19 14 13 1110 <br />1 <br />us DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />IA. Unit <br />No. <br />Type <br />Quantity <br />Wt/Vol <br />ON <br />I I I I <br />N <br />b. <br />, oft <br />2 t <br />f <br />06 <br />J�;;01 <br />0 1011 <br />�10 <br />Tc. <br />d <br />scripticiiis for Materials Listed Above <br />K. Handling Codes for Wastes Listed <br />'A <br />b.� 1h <br />PTA# 17 <br />d.: <br />& Special Handling Instructions and Additional information <br />V <br />R <br />24 0*1 En ne TeL No. CHEM 1-0424-9300 <br />rgM 7 <br />DO 110Wj ear pteme cloirig <br />Bill of Lading 0 10 —37 <br />Sales Order # <br />I& GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment nt are fully and accurately described above by proper shipping name i4d clascl, <br />! , 4 <br />in transport <br />marked, and labeled, and are in all respects in proper condition for tran art highway to <br />according applicable international and national government regulations., <br />If Iain alarge 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 ecis <br />practicable and that I have selected the practicable method of treatment storage, or disposal currently available to me which minimizes the and future threat to human <br />present <br />01`14 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 />available to me and that I can afford. <br />F. <br />Pr /�ATyplslam gnot.", <br />3 Month Day :Year. - <br />1 C2 A 2 <br />R <br />17. TronipcAF61M Acknowledgement of R#cZipt of Materials .4 <br />A <br />P i is I d/T <br />IT Signature s)onth Day Y <br />kens ifoftith AcknowIeJ9eKenf of Receipt of Materials /y// <br />ini"/Td J49meSigncit�e <br />Von <br />;hAr-0 A <br />Y Year <br />.Ch A <br />F <br />19. DiscreAAnZy Indication Space <br />I>F 710 CAC -4.-, k*UA,2-5 44-1F 'A -1A <br />I <br />P9 -06,u Ix A -2r& 011,7 <br />20 F cc, i Owner <br />Ow or Operator Certification of rec Ors tovered by this manifest except as noted in Itern-1 J 4 <br />T <br />'Y' <br />n /Typed No e JS <br />n, CA <br />7onth , D Year <br />Z 6 <br />DO NOT WRITE BEeRW THISJUKE. <br />Yellow: TSDF(SEI 11"S COPY TO GENERATOR WITHIN 30 DAY$,;- <br />DTSC 8622A (1199) (GeneraT6-es"'w'ko submit hazardous waste for transport out -of-st <br />at <br />EPA 8700-22.`` produce completed copy of this copy and send to DISC Swithi,n <br />