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State of Colifom�En6onmerrtal Protection Agency . <br /> Forr4r',Approved OM$No 2050-0039(Expires 9 30.94) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or typp Form designed for use on elite{12-pitch)typewriter Sacramento Cairfamia <br /> 1 Generators US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal low <br /> WASTE MANIFESTcoan Z' of 111 A <br /> 3 Generator s Name and Mailing Address Al <br /> J ,r. ,e1 1y� <br /> o �pCr1 �S T <br /> n �'{ /0 5r <br /> n 4 Generator's Phone {� $�, [J�J C. ��,� <br /> 0 <br /> 5 5 Transporter 1 Company Name 6 US YA ID Number � <br /> 3 <br /> 0 <br /> NVIROFUR WEST C A T O 8 0 0 i i 0 5 9 <br /> 7 Transporter 2 Company Name 8 US EPA ID Number <br /> S <br /> J ' <br /> i� <br /> 9 Designated Facility Name and Site Address 14 US EPA ID Number <br /> ENVIROPUR WEST <br /> 13331 N. HWY. 33 <br /> PATTERSON, CA. 95363 CAD 0 8 3 1 6 6 7 2 8 <br /> 11 US DOT Description(including Proper Slipping Name,Hazard Class and ED Number) 12 Containers 113 Total 14 Unit <br />_ No Type <br /> Gluarrt Wt/Vol <br /> C a <br /> G NON RCRA HAZARDOUS WASTE LIQUID <br /> E 01011 T T l c <br /> 0 N b <br /> Z? E <br /> R <br /> T A <br /> DT c <br /> 0 0 <br /> e R <br /> u <br /> d <br /> u <br /> for <br /> J <br /> u <br /> 7 ^Kai' PA 1 N A,4`e' xi J6Fa 4 £4 C"4b d <br /> 15 Special Handling Instructions and Additional Information } <br />= 24 HR. EMERGENCY CONTACT: FRC #1—($0"A)-874-4444 <br /> 24 HR. EMERGENCY RESPONSE. CHEM TEL INC. #1—(800)-255-3924 <br /> a APPROPRIATE PROTECTIVE CLOTHING & RESPIRATOR. <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 />' packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable federal state and international lours <br /> C r <br /> J <br /> p 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 hove determined to be <br /> 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 <br /> j 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 the best <br /> r waste management method that is available to me and that I can afford <br /> Pnnted/T ped Name Signa re th r <br /> J T 17 Transporter 1 Acknowled emenr of Receipt of Motenois —. <br /> AR Panted/T Na f- re Signature r <br /> N ! <br /> 5o(44 A fj <br /> P <br /> 0 18 Trans orter 2 Ac a ent of Receipt of Materials 10 <br /> TPrinted/Typed Name Signature Month Day Year <br /> E <br />) A <br /> 1 19 Discrepancy Indication Space <br /> 7 <br /> J A <br /> C <br /> 20 Fault Owner or Operator Certification of recer t of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS UNE <br /> Blue GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS <br />)TSC 8022A (7/92) To P O Box 400 Sacramento, CA 95812-0400 <br /> PA 8700--22 <br />