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TEXAS t1ZiK4MIS!9NON O <br />ENVIRON ENTAL QUALITY <br />P.O. Sox 13087 <br />Austin, Texas 78711-3087 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039. <br />U <br />IFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 Information in the shaded areas <br />DocumentNo. of is not required b <br />WASTE MANIFEST q y Federal law. <br />3. Generator's Name and Mailing Address A State Manifest Document Number <br />k <br />B State Genrors ID <br />4. Generator's Phone ) �` <br />5. Transporter 1 Company Name 6. US EPA ID Number StTrnspo4e <br />7. Transporter 2 Company Name 8. US EPA ID Number E Trart <br />F Trrtspoatc''i'ipne <br />9 Desi Hated Facility Name and Site Address 10. US EPA ID Number E cdity <br />11A. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID 12. Containers n T13. otal 14. K I" <br />HM Number and Packing Group) No. Type C+1Faste No <br />Quantity Wt/Vol <br />a. <br />G t`. ___ <br />E b I <br />R <br />A <br />T <br />O <br />R C. <br />d. <br />��Ab <br />d>arig Codes #orltVasteax2ed Ab'pve <br />F� <br />15. Special Handling Instructions and Additional Information 1 <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 I 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 />�r_ <br />Printed /Typed Name Signature Month Day Year <br />) <br />R 17. Transporter 1 Acknowledgement of Receipt of Materials Date <br />A Printed / Typed Name Signature Month Day Year <br />N <br />s <br />P <br />R 18. Transporter 2 Acknowledgement or Receipt of Materials Date <br />T Printed / Typed Name Signature Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />c <br />I <br />20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br />T <br />v Date <br />Printed / Typed Name Signature Month Day Year <br />TCEQ-0311 (REV.09/01/02) White - original Pink -TSD Facility Yellow -Transporter Green -Generator's first copy <br />