Laserfiche WebLink
'State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions ®n backDepartment of Toxic Substances Control <br />Please print or type. Form designed for use on elite (12 -pitch 40- Sacramento, California <br />ME <br />E <br />N <br />Do E <br />v R <br />v A <br />T <br />0 O <br />l <br />C. <br />Nan-RICRA, hazardous waste, WidlRegs & K'sity Litter t.I; of") <br />a,Other <br />d. State <br />z <br />EPA/Other <br />:j <br />Jmarked, <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />If I am a large quontiy generator, I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economical)y <br />have treatment, or disposal currently available to me which minimizes the present and future threat Po human health <br />n <br />is not required by Federal law. <br />WASTE MANIFEST <br />qq-jq1I7130I0 31 71 4 913 <br />of <br />Prin /Typed Name <br />3 Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />23537493 <br />(CGI) <br />B. State Generator's ID <br />A. Generator's Phone ( - ) 9$rr 3y 3 F dn. Kevin Anderson <br />17. Trans orter 1 Acknowled etnent of Recei t of Materials v <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporters 1D [Reserved.] <br />y <br />a� g ; <br />i^a4 TivTT�tt9 Ttf ., 918411'21,51017111514 <br />ICI <br />p. Transporter's Phone232- <br />.7- Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.], <br />fiarjs; odafiafm & PA <br />F. Trans orter's Phone <br />9. Designated Facility Name and Site Address10, US EPA ID Number <br />G, State Facility's ID <br />Pilo Chem ccxlas;rati t't � � <br />*.ICIA Q 0 0 8 3 6,443(21 <br />H. Fac`ili's Phone <br />25 I515 Ayer&W <br />� <br />... <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)No. <br />12. Containers <br />13. total <br />Quantity <br />14. Unit <br />Wt/vol <br />I Waste Dumber <br />Type' <br />a. RQ <br />s, •..aa,aaE-mvninen�allhU� .rdt113Wb lle4$081 lOS9 <br />State <br />EPA Other'0013� R <br />.. <br />M <br />11,11"1, � �. <br />01 3 <br />b. <br />I�Iaarr.F I Izr r�If=.# <br />Spate <br />181 <br />EO Other <br />C. <br />Nan-RICRA, hazardous waste, WidlRegs & K'sity Litter t.I; of") <br />a,Other <br />d. State <br />z <br />EPA/Other <br />:j <br />Jmarked, <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are tully and accurate)y described aoove oy proper snip mg name ana are ciassmeu, pucaeu, <br />and labeled, and are in all respects in proper condition for transport by highway according to applicable international and nationa government regulations. <br />—Ja <br />b <br />If I am a large quontiy generator, I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economical)y <br />have treatment, or disposal currently available to me which minimizes the present and future threat Po human health <br />n <br />practicable and that t sele 1fed the racticable method a storage, <br />and the environment; OR, if 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />a' <br />available to me and that I can afford. j <br />y <br />Prin /Typed Name <br />Signature�,+� ✓'" <br />Month Da Year <br />_ y} <br />Z i= <br />5 T <br />17. Trans orter 1 Acknowled etnent of Recei t of Materials v <br />.0 A <br />Printed/Typed Name ' <br />Signature <br />Month Day Year <br />R <br />rc <br />P <br />7 <br />i 0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />TR <br />Printed/Typed Name I <br />Signature <br />Month Day Year <br />L E <br />R <br />J19. Discrepancy Indication Space <br />Z F <br />A <br />C <br />I <br />L <br />20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />I Printed/Typed Name Signature Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />