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TEXAS'COM MISSION 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 />7-1" <br />Form Approved. OMB No. 2050-0039. <br />TCP&(OfJ IRE1890r 1i ir- i LJ raudny TeHUW-iransporier ureen-uenerator's tirst copy <br />ft 9 0 14 19 1 <br />SZMPL* A 00091 179QI <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />2. Page 1 Information in the shaded areas <br />WASTE MANIFEST -- ' CAD 982501-736.---. n. o <br />of 1 is not required by Federal law. <br />3. Generators Nanerij! Mgili% Ac ss �"� TRANS D!L--V-1-2JLVL1 J.V <br />A. State Manifest Document Number <br />A <br />S 01244674 <br />STOCKTON CA 95206 <br />enerator's ID <br />lb8t6bg <br />209 274-6834 <br />4. Generator's Phone ( <br />- <br />EPA ID Number <br />5,Tgyipler I jo Ry N 6. US0509 <br />gj 'SIRTEMS, INC TXR000050930 <br />C. State Transporters IQ � 7 19 y - <br />6 9 – 57 40 <br />D. Transportees Phone"' <br />7. Transporter 2 Company Name & US EPA ID Number <br />E. State Transporters ID '41063 <br />F. Transporters Phone 9 W/ 1, c?.',3& <br />%kp",?d keMnntyfft dressjNC. 10. US EPA ID Number <br />Otft2 4acility ID <br />1722 COOPER CREEK ROAD <br />H. Facility's Phone <br />DENTON, TX 76208 <br />TXD177603371 <br />. . . . . . . . . . <br />94( 83-5200 <br />4 <br />11A. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, ID <br />12. Containers 13. 14. 1. <br />Total Unit <br />HM <br />Number and Packing Group) <br />No. Type Quantity Wt/Vol Waste No. <br />a. HAZARDOUS WASTE, SOLID, N.O.S. <br />Z 0 <br />X <br />(TETRACHLOROETHYLENE, LEAD) <br />M UTS409H <br />G <br />E <br />9 NA3077 PGIII (ERG#171) <br />Arlo <br />N <br />E <br />71 LF -- <br />R <br />-*Aa <br />A <br />tvt% <br />elf j <br />T <br />0 <br />R <br />C. <br />d. <br />iliNjitic""cro'Igor K. Handling Codes for Wastes ListedAbove <br />Awl <br />15 Special Handling Instructions and Additional Information MF ST R/T#106731679 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. –3-4 =C: D: <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are <br />classified, packed, marked, and labelled/placarded, and are in all respects in prori)er 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 in 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 practicablD 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 m nagement method that is available to me anti that I can afford. <br />Prinfedped Name Month Day Year <br />I/ A -Z-210-j— <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials Date <br />R <br />A <br />Prinje&�Typed Name <br />Signatur Month Day Year <br />N <br />s <br />Z . C, <br />P <br />0 <br />Materials <br />18. Transporter 2 Acknowledgement or Receipt of Materials Date <br />R <br />T <br />E <br />Printedj3yped Name <br />ign u Month Day Year <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />20. F7 Owner or Operator: Certification of receipt of hazardous materials:3,ov red by this manifest except as noted in item 19. <br />T <br />Date I <br />Y <br />—4*7t;qPPd N Sign nth Dag Year L <br />1 i I o <br />I / –1 ILA yj <br />TCP&(OfJ IRE1890r 1i ir- i LJ raudny TeHUW-iransporier ureen-uenerator's tirst copy <br />ft 9 0 14 19 1 <br />SZMPL* A 00091 179QI <br />