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TEXAS COMMISSION ON <br />ENVIRONMENTAL QUALITY <br />P.O. Box 13087 <br />Austin, Teias 78711-3087 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039. <br />TCVEW� WEW�/OM�D �1, (.) 14 19 1, B 0 2 (-Me-seffa I Pink- 15U Facility -Transporter Green -Generators first copy <br />1'� To D T 4 as I n (I (-) 1) 1 1 -7 1i �, 1 R 0 0 4 0 0 E� 4.0 2 r) <br />UNIFORM HAZARDOUS Generator's US EPA ID No.D Manifest age <br />Information in the shaded areas <br />WASTE MANIFEST C-AD9-82501736 . e of i <br />is not required by Federal law. <br />I <br />— <br />3. Generator's Na M�IinbAdSS (-,IAL -J'H91qS DTVI-111va IV 'A. State Manifest Document Number <br />RM d 9T <br />S 01244756 <br />STOCKTON CA 95206 ID <br />209 274-6834 %fteolenerator's <br />4. Generator's Phone ( <br />5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID 87109 <br />SAFETY-KLEEN SYSTEMS, INC TXR000050930. . . D. Transporters Phone 15 V Q <br />7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporters ID q703 <br />X7 �, j eel) . . . F. Transporter's Phone Qy-V2,,(, r,,e-;"71 <br />9. De , tv eNS�$fte PoressINCV V U f:O 16 10. US EPA ID Number G ?fjF cility ID <br />M 0 ? f oy'_F0VE EAR" TE , --. <br />1722 COOPER CREEK ROAD <br />DENTON, TX 76208 H. Facility's Phone <br />TXD077.503.371 . . . 940 483-5200 <br />11A. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, ID <br />12. Containers 13. <br />14. <br />1. <br />HM <br />Number and Packing Group) <br />No. I Type Total <br />Quantity <br />Unit <br />WtIvol <br />Waste No. <br />a. HAZARDOUS WASTE, SOLID, N.O.S. <br />G <br />X <br />(TETRACHLOROETHYLENE, LEAD) <br />-)M <br />P �)UTS409H <br />E <br />9 NA3077 PGIII (ERG#171) <br />N <br />E <br />R <br />b. WASTE SOLIDS CONTAINING FLAMMABLE <br />A <br />X <br />LIQUID, N.O.S. (GASOLINE, BENZENE) 4.1 <br />)M <br />P <br />OUTS409H <br />T <br />UN3175 PG II (ERG#133) <br />f6 <br />0 <br />R <br />C. <br />d. <br />I_jNjtioftWgcrij6bnSpr 4"a"tyd bt&yj D018 OUTS 409H 213 K. Handling Codes for Wastes Listed Above <br />A� <br />/7 <br />15. Special Handling Instructions and Additional Information MFST R/T#106822021 0000-3701-92 <br />EMERGENCY RESP 800-468-1760(24 HR). IF UNDELIVERABLE RETURN TO GENERATOR. <br />SK CORP AUTH'D TO USE SUBSEQUENT CARRIERS: 40343.41038,81681.82739,,86256 <br />SKDOT# A: 22373 B: 34273 C: D: <br />16. GENERATORS CERTIFICATION: I hereby declare that the conterts of this consignment are tally and accurately described above by the 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 applicable international and national <br />government regulations, including applicable state regulations. <br />If I am a large quantity generator, I certify that I have a program ,n place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and <br />future threat to human health 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 <br />the best waste management method that is available to me and inat I can afford. <br />Print1d �/Ted Na e Si �a—� Month Day Year <br />I/ Z1/3 jOr <br />--T—Date <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Print904-jyped <br />Name <br />Signature Month Day Year <br />N <br />S <br />&VA3 t*'140 <br />1/2 1/ 3 10 S- <br />P <br />0 <br />18. Transporter 2 Acknowledgement or Receipt of Materials <br />Date <br />R <br />T <br />E <br />Printed/ T ped Name//,Signal <br />—u irf Month Day Year <br />RI <br />L I <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I— <br />L <br />20. Facility Owner or Operator: Certification of receipt of hazardous materials covered bj this manifest except as noted in item 19. <br />1 <br />T <br />Date <br />Printed / Tt_Na7 <br />TCVEW� WEW�/OM�D �1, (.) 14 19 1, B 0 2 (-Me-seffa I Pink- 15U Facility -Transporter Green -Generators first copy <br />1'� To D T 4 as I n (I (-) 1) 1 1 -7 1i �, 1 R 0 0 4 0 0 E� 4.0 2 r) <br />