|
State alifornia—Environmental Protection Agenq... «
<br />�6.
<br />APP
<br />Se Instructions
<br />QMB No. 2050-0039 (Expires 9-30.94)P
<br />Onback'o age °� ' �De artmentofToxic5ubstaniesControl
<br />PI
<br />ogtype.. Form designed for use on elite (12 -pitch) Typewriter.
<br />Sacramento, California
<br />..
<br />15. ial Handlin Instructions and Additional Information . rt... w.
<br />UNIFORM HAZARDOUS
<br />1. Generators US EPA ID No.
<br />A O 3 . 3€5771
<br />Manifest Document No.
<br />w . '
<br />2. Page 1
<br />..
<br />Information in the shaded areas
<br />is not required by Federal law.
<br />.
<br />W
<br />WASTE MANIFEST
<br />Z
<br />of
<br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified,
<br />Q
<br />3. Generator's Name and Mailing Address 'PACIFIC CUA51 PRUVVUtllt�
<br />packed, marked, and labeled, and are in, all respects in proper condition for transport by highway according to applicable federal, state and international laws.
<br />o
<br />8315 S, STOCKTON - $1
<br />If I am ci 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 />J
<br />Iy practicable have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future ,.
<br />i.1 C}I CA -95240
<br />threatrto humon health and the environment; OR, if 1 am`a small quantify generator, I have made a good faith effort to minimize my waste generation and select the best
<br />to
<br />q
<br />4. Generator's Phone'( { . '334--;,,2,,y5
<br />waste manageinent method that is available to me and that I can'afford
<br />00
<br />6
<br />'.
<br />5. Transporter, 1 Company Name 6. US EPA ID Number '
<br />Sttsaature ;' 1, t t �y
<br />Month Day r,
<br />°,®a
<br />ft T L .E r"ORP O
<br />� '
<br />-
<br />7. Transporter 2 Company Name 8. US EPA ID Number
<br />T
<br />17. Trans orter 1 Acknowledgement of Receipt of Materials
<br />U
<br />W
<br />V
<br />. W
<br />R
<br />N
<br />,
<br />Printed/T edNpme
<br />_ _
<br />Signature
<br />Q
<br />Z
<br />P
<br />0
<br />18. Tronspoiter 2 Acknowled ement of Recei t of Materials I
<br />9. Desi noted facility Name and Si Address 10. SEP Nu b r
<br />*913 F',
<br />91A ,
<br />ce
<br />O.<W1
<br />, i
<br />wq'��KiE�(E[y��I{q�{ywt
<br />X41 "�f'1: V,.FR' MA �S•�•,','
<br />i6
<br />Signature
<br />Month Doy Year '
<br />u_
<br />-CAT 000613968"
<br />to
<br />Z
<br />11 U5 DOT Description (including Proper Shipping, Name, Hazard Class, and ID Number) ,
<br />F
<br />12 Containers
<br />No
<br />13. Total. 14. Unit:
<br />Type QuantityWt/YOI ;
<br />LO
<br />WAST
<br />Z
<br />C
<br />Cti 3
<br />G
<br />0LXUM . WAPAT��i� )lel i S�3P`011 l � +�O l ?
<br />C4
<br />E
<br />, 04 27 } 6. 7 LOS.,/GAL
<br />covered b this manifest except as noted in Item 19.
<br />65
<br />E
<br />b IN4y, WASTE. COMPOUt4MCLEi D
<br />.
<br />Y
<br />'
<br />(1-10NOFTHANOLAM iN 4 8' A1760 PGIII�
<br />M
<br />V
<br />!
<br />A
<br />(3)(ERG60]t
<br />C.
<br />--:00
<br />®®
<br />F–
<br />d
<br />w
<br />W
<br />..
<br />Z
<br />O'
<br />..
<br />15. ial Handlin Instructions and Additional Information . rt... w.
<br />Q
<br />Z
<br />.
<br />W
<br />SKDO? JCS 566 C : �w
<br />Z
<br />J
<br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified,
<br />Q
<br />packed, marked, and labeled, and are in, all respects in proper condition for transport by highway according to applicable federal, state and international laws.
<br />U
<br />If I am ci 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 />J
<br />Iy practicable have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future ,.
<br />D.I
<br />N
<br />threatrto humon health and the environment; OR, if 1 am`a small quantify generator, I have made a good faith effort to minimize my waste generation and select the best
<br />waste manageinent method that is available to me and that I can'afford
<br />0G
<br />O
<br />'.
<br />Pri d/Typed Name `
<br />Sttsaature ;' 1, t t �y
<br />Month Day r,
<br />U
<br />T
<br />17. Trans orter 1 Acknowledgement of Receipt of Materials
<br />W
<br />V
<br />. W
<br />R
<br />N
<br />,
<br />Printed/T edNpme
<br />_ _
<br />Signature
<br />Months. Day Year
<br />li
<br />P
<br />0
<br />18. Tronspoiter 2 Acknowled ement of Recei t of Materials I
<br />tL
<br />, i
<br />Printed/Typed Name
<br />i6
<br />Signature
<br />Month Doy Year '
<br />u_
<br />R
<br />to
<br />19. Discrepancy Indication Space
<br />to
<br />Q
<br />F
<br />Z
<br />C
<br />e
<br />k
<br />I
<br />20. Facilitywner or Operator Certification of receipt of hazardous materials
<br />O
<br />covered b this manifest except as noted in Item 19.
<br />T
<br />Printed/Typed Name
<br />Signature
<br />Month Day Year
<br />Y
<br />DO NOT WRITE BELOW THIS LINE.
<br />DTSC 022A (7/92)
<br />EPA 87700-22 Yellow: GENERATOR RETAINS
<br />
|