Laserfiche WebLink
State of Colitornic—E—ronmentai rrotection Hgency <br /> -`form.Approved OMB No.2050-0039(Expires 9-30-94) See 1f15tr�ICtlOfis Oft back Of Cige 6. ep merit of toxic Substances Con-; <br /> Please print or type. Form designed for use on elite(72-pit writer. s Sacramento,Californic <br /> Generators US EPA ID No. Manifest Documen 2. Page 1 Information in the shaded areas <br /> .UNIFORM HAZARDOUS <br /> 7,' <br /> 8 is not required by federal law. <br /> WASTE MA{�1'lFEST C A 2 9 0 0 9 0 0 2 4 1 1 " of :#'" <br /> 3. Generator's Name and Mailing Address <br /> 0to L.lvf-rm r S ,3d0 <br /> 7040 East Avenue, Livemnom, CA 94850 <br /> LO 4. Generator's Phone 610 )422-IM A Wilt `-620 <br /> 09 <br /> 0 5. Transporter 1 Company Name 6. US EPA ID Number - <br /> 0 Erickson, Inc D m ite <br /> JA D0 101914 16 113 13 19 12 ._ <br /> �J <br /> - 7. Transporter 2 Company Name 8. US EPA ID Number E <br /> U <br /> 00 E <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number C3 Qie oetPAj� D <br /> W ERICKSON INC. <br /> coo <br /> LL 255 Parr Blvd., Ric hmor4 CA 94801 <br /> �� !00094g63IE2 � <br /> Unit <br /> U <br /> Total 14 <br /> Containers 13. . n <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. <br /> No. Type Quantity Wt/Vol as4 urhbei' <br /> Non R <br /> NCRA Hazardous Waste,Solid (Empty Containers Last CDnitainirg <br /> G Diesel Fuel)(vitt,associated gong) 0 T P <br /> o E00 � <br /> N b. 1 r;,iOlp �� Y <br /> 00v EQM 4 <br /> Nv R EPA'Otho t a , <br /> O T C. <br /> 0 State s, <br /> O v yts - <br /> R EP„A`Otf>Pr LUa <br /> Z d. Stote <br /> Un a. <br /> � EPA f Other - <br /> Z bJ Adddidnol Descriptions for Materials listed Above :' 1 `.v ' 9 £ � ��r <br /> p §a "� x K fia`ndfing codes for 4Vcsfes =`bo >^^x <br /> LU <br /> �a <br /> 7r].. j t^ <br /> o- <br /> s <br /> 0 15. Special Handling instructions and Additional Information <br /> EMERGENCY CONTACT:(510) 447 <br /> Z Wear protective,dotWng vAge handkV, These materials are NOT radbactively contmninated _ <br /> = HWM R n Num KI357 , H1357B7 I3 Gou#1%w7W ut <br /> JJ 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 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 /> JIf I am a large quantity generator,1 certify that I have o.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 <br /> g spo currently available to me which minimizes the present and future <br /> N threat to human health and the environment;OR,9 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to and that I can afford. <br /> 0 Printed/Typed Name —7Signauret <br /> Month Do Year , <br /> u R 8 Loden behalf of UNL Q G jj{ <br /> Z T 17. Transporter 1 Acknowled ement of Receipt of-Materials <br /> w R Print T ed o <br /> O T t Signature Mo h Da Ye <br /> % <br /> N <br /> W S <br /> P <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> W R <br /> U- T Printed/Typed Name Signature - Month Day Year <br /> O e <br /> W 19. Discrepancy Indication Space <br /> . N <br /> UF <br /> A <br /> Z C <br /> _ I <br /> L - <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed Ted NSig re Morrth _ Day Year <br /> v Printed/Typed Nome <br /> DOAK . . THISUNE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> Z°°"ff2jpil r4 rr,: t (Generators who submit hazardous waste for transport outofstarte, <br /> v "� v s6cwx .Y <br /> produce completed copy of this copy and send to DTSC within 30 days.) <br />