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.hMad Welfare Agency - ; -
<br /> iw No.2050•--gp39(Expire*9,31}91) DsOartment of Health Services
<br /> A0. (Form designed for use on elks(12p ,pewrife►). Toxic Substances Control Division
<br /> .oNIFORM HAZARDOUS I. Geriermor's US EPA ID No. z I I Sacramento,California
<br /> .-mMi 191 PTO 1 Information In the shaded areas
<br /> WASTE MANIFEST C� d e A n A ;; G r; i,/ ° 1a not 3. Generator's Name and M911ing AcWeu r required by Federal law.
<br /> l to : .t .4 r'T.R,/i l I �-�1 4 P/YT 1 A.:State Mani st unjpnS►LjNu b
<br /> . •.•r 7 '�i�se,r' t.;r�..il ,;Tv:x•T��tr:';�'�`ilS .. S- _ ;.; �:..,
<br /> 4. General `. 'tA ,•: r I �,�. Stlf' a
<br /> Of'a PhOM(r A. Fr ,Y:( '~�.�'.� l i
<br /> 6. Transporter 1 Company Name 8. US EPA 10 Number C. State Tran
<br /> r11 !i rti Pe: eulu C A J i1 O 7 M
<br /> b 1 t! D. Tr•nsponerPne D M• T
<br /> 7. Transpor{er 2 Comp my N e , 8, US EPA ID
<br /> 1 1 tfr' 1. V „ Number E. Stale Transporter e.to
<br /> ief, .- 1 F. Transporter's PhatVa;^!r..•:,,. - ..
<br /> 9. Designated Facility Name and Site Address 10. US EPA iD Number G..Slate FecflNy'a b i�` ;r• '
<br /> :� iliierS>ry $Ct^YICtJW 33 1: iattersQ11 ::. .
<br /> : .C`A..0.,a,.8-' I.
<br /> .
<br /> irA � )f..Facility's Phots.
<br /> 53631 C H ' U b 3 I ii ti 7 f i:>:- r:.;.;.�•
<br /> u j 874-�44�i:���N: 3:., n.;.
<br /> 11. US DOT Description pnTotal 14.
<br /> cluding Proper Shipping Name,Hazard Class,and 10 Number) 12. Camainero 13.Quantity 'Unit s i? Waste No.,'`{
<br /> a. No. Type Wt/Vol `
<br /> a TE FUEL 4.&UJSTI#1;Li LIQUID
<br /> y T ji o EPA/ocher.
<br /> E b.
<br /> A i .Slate
<br /> Tq..,.,
<br /> ! ; EPAtOlher
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<br /> R o.
<br /> . . � . . State..
<br /> EPA/Other'...
<br /> d.
<br /> State.
<br /> • EPA/Other
<br /> I Additional Dest:ripllons for Materials Listed Above K Handling Codes for.Wastes 4 fated Above u i
<br /> 9 JX- MATER Ahs,:A LLAT :�;•,N,;:^ L.:. :.•,;: .i. ..:,: ; 'b•
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<br /> 44.
<br /> A W.L. :'f: ,,, ,'t:i-,;::r', ,t-:i:, .n:.•:.l.i�i:
<br /> 14 4
<br /> ,l{. :'4. wi?-•Y''' ..A.: .
<br /> 16. Special Handling Instructions and Additional Information
<br /> • "1 .,r
<br /> flat Au•nupRiArci nareCTiVE uAR
<br /> vL•41GlIAM) FACILITY ENERi t'tCY.CONTACT i� (600)474-"44
<br /> ti;,�:ZRATCIR%Z-li AjENCY CUhTACT it tn;'t} i.;I- 3.3
<br /> 18.
<br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name
<br /> and aro classified•packed,marked,and labeled,and are In all respects Ire proper condition for transport by highway according to appi{cable International end
<br /> national government regulatibhs.
<br /> If 1 am a large quantity generator,I certify that 1 have a program In place to reduce the volume and toxicity of waste generated to the degree 1 have determined
<br /> to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the
<br /> present and future threat to human health and the environment:OR,If 1 am small quantity generator,I have made a good faith effort to minimize my waste.
<br /> generation and select the best waste management method that Is available to me and that 1a can afford.
<br /> Primed/Typed Name « , Signature
<br /> r;.. , fi v Month Day Year
<br /> R17. Transporter 1 Admowledgameni of Receipt of Materials ;
<br /> NPrMted/Typed Name ! Signature' Afwtth Day Year
<br /> O 18. Transporter 2 Acknowledgement of Receipt of Materials
<br /> T Printed/Type To, j
<br /> j Signet ur j .�• Afonth Day Year
<br /> 19. Discrepancy indication Space ,. v
<br /> C !
<br /> 120. Facility Owner or Operator CeltMlcation of receipt of hazardous materials covered by this manliest except qa lroted In hem 19.
<br /> y Primed/Typed Name SIOa
<br /> ature i Month Day Year
<br /> t' /•)r �•f �� ', .%d. :.fly/'~` •. ! + i'f /�
<br /> 9022 A(1166) I Do Not Write Below This Liffe. '
<br /> 1700-22 i
<br /> 9.88)Previous edillons are obsolete. I ::
<br /> GREEN: HAULER RETAINS
<br /> �+ _.
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