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TEXAS COMMISSION ON <br />ENVIRONMENTAL QUALITY <br />P.O. Box 13087 <br />Austin, Texas 78711-3087 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />4, <br />-- - --- Form Approved. OMB No. 2050-0039. <br />j Whueoriginal DF-acflit Yellow -Transporter Green -Generator's firs T copy <br />__47 -,,al Pink-fb <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />2. Page 1 Information in the shaded areas <br />'07 <br />T . . . u No. <br />WASTE MANIFEST <br />Of � not <br />is not required by Federal law. <br />, <br />3. Generator's Name and Mailing Address 7 <br />A. State Manifest Document Number <br />01230586 <br />B. State Generator's ID <br />4. Generator's Phone )2'7 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's-ID-8-7 -i t) `_- <br />T J <br />D. <br />D. Transporter's Phone, <br />7. Transporter 2 Company Name r 8. US EPA ID Number <br />,.,`7A <br />E. State Transporter's lb 6/ 03 <br />17pn47,4 i <br />F. Transporter's Phone <br />9. Designated Facility Name an Site Address-, . 10. US EPA ID Number <br />G. State Facility ID <br />AFF T Y - E' F N T '-,I <br />5124 <br />H. Facilitys Phone <br />'i�x <br />7 21 ulna <br />11A. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, ID <br />12. Containers 19. 14. <br />t. <br />HM <br />Number and Packing Group) <br />No. Type Total Unit <br />Quantity wt/vol <br />Waste No. <br />G <br />E <br />N <br />AS D <br />R <br />A <br />ETT PI A, T T T <br />")UTS <br />409H <br />T <br />j_ <br />0 <br />R <br />C. <br />I <br />d. <br />J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br />1 B I D 0 0 8 D0,39 3S2 <br />15. Special Handling Instructions and Additional Information M T f;` P 00 <br />4 4 4 <br />n <br />C T 4 P <br />16. GENERATORS 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 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 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 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 hat is available to me and that I can afford. <br />Printed / T NamSignature Month Day Year <br />�ped <br />T <br />17. Wa­nsporte'r jAckno a ement of Receipt of Materials Date <br />R <br />A <br />P i d / Typed Name <br />Signature • Month Day Year <br />N <br />s0 <br />J/d j <br />P <br />0 <br />18. Transporter 2 Acknowledgement or Receipt of Materials <br />Date <br />R <br />T <br />E <br />- <br />Printed / Typed Name <br />ITig—nature Month Day Year <br />R <br />A4 <br />19. Discrepancy Indication Space <br />L <br />s <br />20. Facility Owner or Operator: Certification of receipt of hazardous mateIs covered by this manifest except as noted in item 19. <br />1 <br />T <br />Y <br />% Date <br />Printed / Typed Name <br />Month Day Year <br />j <br />j Whueoriginal DF-acflit Yellow -Transporter Green -Generator's firs T copy <br />__47 -,,al Pink-fb <br />