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TEXAS IbOMMISSION ON <br />. •-L 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 />UNIFORM HAZAFDOUS 1. Generator's US EPA ID No. <br />WASTE MANIFEST r, <br />3. Generator's Name and Mailing Address -: <br />4. Generator's Phone ( ) <br />5. Transporter 1 Company Name <br />7. Transporter 2 Company Name <br />9. Designated Facility Name and Site Address <br />Y i ! N `— <br />N' T . <br />G <br />E <br />N <br />E <br />R <br />A <br />T <br />O <br />R <br />6. US EPA ID Number <br />r ,; <br />8. US EPA ID Number <br />a.7,P.'7.e'.6 <br />10. US EPA ID Number <br />11 A. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID 12. containers 13. 14. ; <br />HM Number and Packing Group) No. Type Total Unit �e N#� . <br />Quantity WtNol <br />T 17.'Transporter 1 Acknowleclgem t of Receipt of Materials <br />R <br />A Printe Typed Name <br />N ^y y <br />L+� <br />P <br />0 18. Transporter 2 Acknowledgement or Receipt of Materials <br />R <br />T <br />Printed / Typed Name <br />R �.%�/i V S CC3 7/ <br />j 19. Discrepancy Indication Space <br />FI <br />Signature <br />Date <br />Month Day Year <br />Date <br />Month Day Year <br />ID•�10-.210s- <br />T 20. Facility wner or Operator: Certification of receipt of hazardous materials cov d by this manifest except as noted in item 19. <br />Date <br />Y - ^ i i <br />TCE9-0311, (13EV.09/01l92).. , <br />White original Fink-TSD <br />� Facility Ye -flow -Transporter Green -Generator's <br />j ®, � ® <br />a r /.h ii ,,"a'�' f a ,. <br />�.L.2 �`'�"TL �; i3` L r. q.. <br />_it <br />0LB$.«5, <br />1 <br />b <br />r r ' f T <br />�y� <br />A. <br />C. <br />d. <br />T 17.'Transporter 1 Acknowleclgem t of Receipt of Materials <br />R <br />A Printe Typed Name <br />N ^y y <br />L+� <br />P <br />0 18. Transporter 2 Acknowledgement or Receipt of Materials <br />R <br />T <br />Printed / Typed Name <br />R �.%�/i V S CC3 7/ <br />j 19. Discrepancy Indication Space <br />FI <br />Signature <br />Date <br />Month Day Year <br />Date <br />Month Day Year <br />ID•�10-.210s- <br />T 20. Facility wner or Operator: Certification of receipt of hazardous materials cov d by this manifest except as noted in item 19. <br />Date <br />Y - ^ i i <br />TCE9-0311, (13EV.09/01l92).. , <br />White original Fink-TSD <br />� Facility Ye -flow -Transporter Green -Generator's <br />j ®, � ® <br />