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08/28/95 MON 14:47 FAX 583 3,282 <br />State of Prolectim Agency <br />Form Appy OPAR No- 205 04)039 (Expires 93094.1 <br />MCI <br />LU <br />See Instructions on back We & <br />M <br />l7ep-f-cry of Toxic —Sbuanms cam <br />sarrannento' CaGtarria <br />6 <br />1. Generafte. US EPA ID No. Manifest Document No. age I In am�an l" at The sisadsdasses <br />UNIFORM HAZARDOUS <br />is not required by Federal low, <br />WASTE MANIFEST <br />1 Generator's Nome and Mailing Address X% at Number <br />Hem <br />0 7 <br />'UFLT'?A1MAR <br />!"� 14m:gm s 8. State Genovalor's ID <br />A. ��Mfcer's Phone ( ) <br />I <br />S. Transporter I Cosapcnv� Nome 6. US EPA ID Number <br />'j— <br />15 o <br />71L <br />Fs D, <br />-r L-L�L- LL—i 1, <br />D.Trate porter's Phone <br />P. Tronsportei'2 Covnr�6ay N" 8, LIS ETA 01 =i6wr <br />E. State Transporter's in--J-4-1- <br />F. Tramparter's Phone <br />9. Designated Facility Nome and Site Address Ifl. US EPA ID Number <br />Slow Fac9ity's fit <br />I I US DOT Descriptkm (Including Proper Shipleing Norne, Howrd Class. and ID Number) <br />12' c6momers <br />13. 11901 <br />14 Unit <br />Na. <br />Quantity <br />wt/Vol <br />1. wuju lNiumitce. <br />U. <br />State <br />RESTDIJE 17ASSOLI-V TANX <br />51z <br />G <br />E <br />NON-RCIA HAZARDOUS WASTI: SOLI'r- <br />. -- <br />4"!')L�) <br />? <br />EPAJOIllet r <br />N <br />b. <br />State <br />E <br />RI <br />EPA/Chhr <br />A <br />I <br />ff <br />T <br />State <br />0 <br />R <br />EPA/Other <br />d. <br />stale <br />EPA/0ther <br />J. Additional Descriplians fee Moderiuk Usled Aba" <br />K. Handling Codes lot Wastes Listed Above <br />EMPTY 12,000 gallon steel tank Imptcont*ininq <br />01 <br />ga.8b. <br />aline. Tank inert ed with dry ice for xafe- <br />trana rt. <br />PROPINO #A4687 <br />15. Special Handling lmtra ions and Additional freformahon, <br />JOB #15484 JOa A*TTS: BEACON STATION, 45q2 <br />2 H. Emerap_ncy Contact: 74 4i4l-5's 541-433-5 '115 Xcrti Cherokee <br />16. GENERATOR'S CERT WICATION.- I hereby declare that the coritents of this consignment are fully and accurately described above by proper iNpping name and are dassifW, <br />packed, marked, and labeled, and are in all respects in proper candition for transport by highway according to appli—bliternfional and national government regulations. <br />If I am a large clucentily geaerafty, I certify shot I have a program in place to reduce the "lame and toxicity of waste generated to the degree I have dater"ned to be <br />econoteicolly proctivabie and that I harre selected the prunficable aurthad of treannent, storage, or disposal currently available so me •vhicb minimires, the pr em and future <br />threat to hvenon, hetith and the emireassam, 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 />--rvast managamsvemethod that is ov®llahk to me d I can d. <br />YT End Nerve, Month Day i��I Yew <br />= <br />1%j In ty"Tu INN Nj <br />17, TK22"or I venal of Re2biof Materials <br />A <br />Prieted/TypedMo.. <br />Sigr�otunn <br />MontleDay Year <br />S <br />'ROPERT -4RS'VV-R <br />0 <br />18. Transporter 2 Adm wiledgement of ReceiptfMaiqricds <br />T <br />Printed/Typed Nam Signature Month D" Year <br />E <br />R <br />L <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I. <br />b this manifest exc as noted in Item 19. <br />00 NOT WRITE 13ELOW THIS LINE. <br />®TSC 8022A 19M <br />EPA 87OD-22 <br />Month Day Year <br />