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-TEXAS 'OOM ISSION 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.) 40 <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. <br />WASTE MANIFEST . . . . . . . . . . . <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 />6. <br />US EPA ID Number <br />8. <br />US EPA ID Number <br />10. <br />US EPA ID Number <br />w <br />Form Approved. OMB No. 2050-0039. <br />2. Page 1 Information in the shaded areas <br />Of is not required by Federal law. <br />MOVNW <br />11A. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID 12. Containers 13. v <br />HM Number and Packing Group) No. Type Total <br />Quant <br />a. <br />G <br />E <br />N <br />E b. <br />R <br />A <br />T <br />O <br />R C. <br />9 <br />15. Special Handling Instructions and Additional Information <br />I <br />Unit <br />Wt/vol <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 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 that is available to me and that I can afford. <br />Print / ped Name Si r Month Day Year <br />b A 2.3 s" <br />R 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br />A Printed ped Name Signat e --Month Day Year <br />"sti/h oj\% /3CA e K 0. Zj Z. 3 10 J_ <br />R 18. Transporter 2 Acknowledgement or Receipt of Materials Date <br />T Print /Typed m Signature Month /Day Year <br />E /• <br />R Q <br />19. Discrepa y Indicat on Space <br />L 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />1 <br />T Date <br />Y <br />Printed / Typed Name Sign Montb Day. Year <br />TCEQ-0311 (REV.09I01102) r- White original fink -TSD JFcilityy Yellow -Transporter Green -Generator's first copy <br />se1 <br />