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TE ' ;MMISSION ON <br />EN . aRr MENTAL QUALITY <br />P.O. Bo>. 13087 <br />Austin, Tezas 78711-3087 <br />Plaaco print or tvna_ (Form desioned for use on elite (12 -pitch) tvoewriter.) <br />40 Form Approved. OMB No. 2050-0039. <br />TCQ-0311 (REV.09/01!02) <br />VVnlie - Onglnal - rIl IK- i OU rd{Jillty t UIIUw- I i m uNUo icj roti I — o Ri o1 I.,ry <br />UNIFORM HAZARE 1 •Generator's US EPA ID No. Manifest <br />2. Page 1 Information in the shaded areas <br />WASTE MANIFEST <br />of is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />t V 947 <br />B. State Generator's ID <br />4. Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID,,, ; <br />D. Transporter's Phoney <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />-, 'e Ab R <br />F. Transporter's Phone <br />9. Designated Facility Name a6dSfe Address 10. US EPA ID Number <br />G. State Facility ID <br />H. Facility's Phone <br />11A. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, ID <br />12. Containers <br />13. <br />14. <br />I <br />HM <br />Number and Packing Group) <br />No. <br />Type <br />Total <br />Quantity <br />Unit <br />WtNol <br />Waste No. <br />a. <br />1. <br />G <br />00 <br />E <br />N <br />E <br />b <br />R <br />A <br />2 <br />T <br />O <br />R <br />C. <br />d. <br />J Additional Descriptions for Materials Listed Above <br />K. Handli Codes for Wastes Listed Above <br />15. Special Handling Instructions and Additional Information <br />16• GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately <br />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 <br />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 <br />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 <br />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 that I can afford. <br />Printe / ed Name Signa <br />Month Day Year <br />Jos <br />T <br />17. ns Traorter 1 Acknowledgement of Receipt of Materials <br />Date <br />R <br />A <br />Prin Typed Name <br />Signature <br />Month Day Year <br />0 <br />18. ansporter i Acknowledgement or Receipt of Materials <br />Date <br />R <br />T <br />Printed / Typ me <br />ur <br />Month Day Year <br />R <br />1! <br />19. Discrepancy Indication Space <br />F <br />A <br />1 <br />i <br />20. Facility ner or Operator: Certification of receipt of hazardous materialscov red by this manifest <br />except as noted in item 19. <br />T <br />Y <br />Date <br />to ped Na <br />Sig reh <br />a Year <br />TCQ-0311 (REV.09/01!02) <br />VVnlie - Onglnal - rIl IK- i OU rd{Jillty t UIIUw- I i m uNUo icj roti I — o Ri o1 I.,ry <br />