Laserfiche WebLink
4 <br /> State of California—Environmental Protection Agency <br /> Form Approved OMB No 2050-0639(Expires 9 3496) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on elrte(12pnch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA ID No Manifest Document No 2 Page 1 Information,n the shaded areas <br /> WASTE MANIFEST j. ` ( �-� r `% is not required by Federal law <br /> � � ! { of <br /> 3 Generator's Name and Mailing Address ! A State Manifest Document <br /> n -1C7 5 JC14 <br /> m4 Generators Phone E2 t ��� 11 ri. � � �, B Slate Generators ID <br /> 5 Tropportet 1 Company Name -} 6 US EPA ID Number C State Transporter's ID J <br /> D Transporters Phone <br /> Cl Al T 101 EJ 6101 jRMJ <br /> a 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's ID <br /> U <br /> Q I I I I I I I I I I IF Transporter's Phone <br /> t Z 9 Designated Facility Name and Site Address 10 US EPA ED Number G State Facddy's ID <br /> 0 VFC Pc&TTER50N, 1NG. I cl AlDI 018131 116161712181 <br />_ .r 3331 Di. HTi . 33 H FacdAlrs Phone <br /> U PAT'sERSOL. GA. 9536 JQ1,dD1 (,41aJ 1 67 - 1 .9 Ann A A—AkA6 <br /> Z 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) 12 Containers 13 Total 14 Unit <br /> a No Type Quantity Wt/Vol I Waste Number <br /> State <br /> 7 3 223 <br /> EPA/Other <br /> O G NUN RCRA HA�s.I1aUS �kra 1TE LIQUID (; �+ i T' <br /> 00 N b State <br /> 4 E Petroleum Recycling Corporate m nt o}� EPA/Other <br /> e <br /> d R ion certifies that the a o <br /> A waste(s), more e <br /> Fence tu t!IE-Wdsle <br /> cp T c set forth above, Was were recycled in ac ordan Banit n stale <br /> UJI IX <br /> R the provisions of 40CFR261 6 and 23 4 pursuant to C- 2C(2) hazardous )A4QRte gergelrate <br /> EPA/other <br /> d recycled in accordance with the provision rof 40CFR fi6ecycling EtfOr�Su e state <br /> P ETR pa EPA/other <br /> J Additional Descriptions for Matenals Listed Above -k-YcihWrt41Codes for Wastes Listed Above <br /> tall p v a b <br /> « ktATER & OIL o T ...,,,' <br /> a <br /> d <br /> Z <br /> 0 15 'Special Handling Instructions and Additional Information <br /> P <br /> 24 HR. FFI RGENCk CONIAM PICC 1j11-(%8G0)-S74-4444 <br /> 24 RR. RIBRGENCI RLSPONSE: CHU1 TEL INC;. #1-k800-255-Y-124 <br /> LU <br /> AprR'oPRiATE PROTECTIVE CLOTHING & P.ESF1R-1Vr0-.. <br /> 16 GENERATOR S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified <br /> a packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> U <br /> If I am a large quantity generator I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to bei <br /> U) economically practicable and that I hove selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future i <br /> 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 generahcm and select the best <br /> cc 0 waste management method that is available to me and that I can afford, r <br /> Pnildt/Typed Name 11 t t1gnature ) J+ Mo <br /> � -7 <br /> Z T 17 Trans orter 1 Acknowledgement of Receipt of Materials 1 f} <br /> W R <br /> f.9 A Panted ype N e" t Signatures <br /> t� P yr C9 N <br /> O 18 Tramporter 2 Acknowledgement of Receipt of Materials <br /> U. T Printed/Typed Name Signature Month Day Year <br /> 0 E <br /> R <br /> N19 Discrepancy Indication Space <br /> a <br /> V A <br /> I C—L (a., (72� L 1� v �c41L <br /> I 20 Fact Owner or Operator Certification of rete, t of hazardous materials covered this manifest except as noted in Item 19 <br /> T Printed/Typed Nome ` re > • / s Mo Daly Year <br /> 7 <br /> DO NOT W ITE BELOW THIS LINE <br /> DTSC 8022A (9/94) 151 s,, I& <br /> �-,��.^c T441c "On '-C' EF'�r A''Df W(Tl'f• "a� DA"S <br /> EPA 8700-22 r& J -J- �n ­-Ir. nr,:tj a:u, Ma Wt {nr ti nnapr,, Sri It 0, <br /> p�C a7L. ..Gn AY Li CL- nr tr,l > anG Sn ra' tl L+'J♦ wt'� S Qv <br />