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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 (' <br />77 -UNIFORM HAZARDOUS <br />13 Generator's Name and Mailing Address - <br />9. Designated Facility Name and Site Address <br />6. US EPA ID Number <br />8. US EPA ID Number <br />yf. �. 2 yz <br />10. US EPA ID Number <br />ME --A <br />Form <br />2. Page 1 <br />of <br />Dved. OMB No. 2050-0039. <br />Information in the shaded areas <br />is not required by Federal law. <br />11A. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID 12. Containers 13.E 14 <br />HM Number and Packing Group) No. Type Total Unit <br />n.—fi— 1A/TA/nl <br />45. Special Handling Instructions and Additional Information - - <br />=', E :i <br />! _ <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 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 1 have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or d' pos 1 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 a g d faith effort to minimize my waste generation and select <br />the best waW management method that is available to me and that 1 can afford. <br />Name 6 l A fgl­� ( Month Day Year <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />a• <br />Date <br />; <br />A Printed / Typed Name <br />Signatur <br />Month <br />Day <br />G <br />P c <br />E IF <br />10-S <br />0 18. Transporter 2 Acknowledgement or Receipt of Materials <br />Date <br />E® <br />R Pri e��ryd / Typed�me <br />orf Signature <br />Month <br />Day <br />�Year <br />(� // y <br />R .l!•'�.' l"' (-�C� ` "� 6C lam—'• G- .-.i�. _ <br />N <br />b <br />F <br />E <br />R <br />1 <br />! - <br />- <br />L 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />i <br />T <br />T <br />Y <br />_ - _ <br />Z <br />�2�6 <br />Signature ; <br />X <br />Day <br />Year <br />S, <br />SI <br />a <br />QS <br />White original Pink -TSD Facility Yellow -Transporter Green -Generator's first copy <br />OR <br />TCEQp31,1(REV.09/01(02) , . <br />c <br />d. <br />45. Special Handling Instructions and Additional Information - - <br />=', E :i <br />! _ <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 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 1 have determined to be <br />economically practicable and that I have selected the practicable method of treatment, storage, or d' pos 1 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 a g d faith effort to minimize my waste generation and select <br />the best waW management method that is available to me and that 1 can afford. <br />Name 6 l A fgl­� ( Month Day Year <br />T 17. Transporter 1 Acknowledgement of Receipt of Materials <br />Date <br />A Printed / Typed Name <br />Signatur <br />Month <br />Day <br />Year <br />P c <br />10-S <br />0 18. Transporter 2 Acknowledgement or Receipt of Materials <br />Date <br />R Pri e��ryd / Typed�me <br />orf Signature <br />Month <br />Day <br />�Year <br />(� // y <br />R .l!•'�.' l"' (-�C� ` "� 6C lam—'• G- .-.i�. _ <br />` <br />19. Discrepancy Indication Space <br />F <br />1 <br />L 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />i <br />T <br />Y <br />Date <br />Printed / Typed Name <br />Signature ; <br />Month <br />Day <br />Year <br />S, <br />SI <br />a <br />QS <br />White original Pink -TSD Facility Yellow -Transporter Green -Generator's first copy <br />TCEQp31,1(REV.09/01(02) , . <br />