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'TEXAS COISSION O ENVIRONMENTAL QUALITY P.O. Box 13087 Austin, Texas 78711-3087 'lease print or type. (Form designed for use on elite (12 -pitch) typewriter.) UNIFORM HAZARDOUS Fl -Generator's US EPA ID No. WASTE MANIFEST 3. Generator's Name and Mailing Address G E N E R A T O R 0 Form ifest 2. Page 1 �ht of 6. US EPA ID Number 8. US EPA ID Number o -KD -`1 .j S, V 311 f 10. US EPA ID Number tj 11A. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID 12. Containers 13. HM Number and Packing Group) No. I Type Total Quant :)ved. OMB No. 2050-0039. Information in the shaded areas is not required by Federal law. 14. Unit C 15. Special Handling Instructions and Additional Information i`� sSf P, /T 1 . ^ 6 4� d, .i.+3/j '<� ["t }�: }AV i34 - ?F E 'D;'_F T' t 2 - iJ -: U - 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 classified, packed, marked, and labelled/placarded, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations, including applicable state regulations. 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 economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have madg a good faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. � 1.-1 Name T 17. Transporter 1 Acknow R A Pri d / Typed Name N S P 0 18. Transporter 2 Acknow R E P d. /�Ty{�e�l Name E �➢ ` N R V 19. Discrepancy Indication Space of Receipt of Materials Signature �CAr or Receipt of Materials Signature Month Day Year Date Month Day Year 1,/ .0 Date i i 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. T Date Y Printed / Typed Name I CAgn nth Day YeaWXIJ�:r 120ce TCEQ 0311 (REV 09/01/02) White riginal ink -TSD Facility Yel w -Transporter Green -Generator's first copy _. a. 6IFl. i b. Ji r E 4. 1 C. C 15. Special Handling Instructions and Additional Information i`� sSf P, /T 1 . ^ 6 4� d, .i.+3/j '<� ["t }�: }AV i34 - ?F E 'D;'_F T' t 2 - iJ -: U - 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 classified, packed, marked, and labelled/placarded, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations, including applicable state regulations. 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 economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have madg a good faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. � 1.-1 Name T 17. Transporter 1 Acknow R A Pri d / Typed Name N S P 0 18. Transporter 2 Acknow R E P d. /�Ty{�e�l Name E �➢ ` N R V 19. Discrepancy Indication Space of Receipt of Materials Signature �CAr or Receipt of Materials Signature Month Day Year Date Month Day Year 1,/ .0 Date i i 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. T Date Y Printed / Typed Name I CAgn nth Day YeaWXIJ�:r 120ce TCEQ 0311 (REV 09/01/02) White riginal ink -TSD Facility Yel w -Transporter Green -Generator's first copy _.