Laserfiche WebLink
Agency <br /> „p;;es 931194) See Instructions on back of page 6. Department of Toxic Substances Conn, <br /> e for use on efite(12-pitch)sypewrimz, Sacramento,California <br /> .gRM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFESTnot required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Address .. A. State Manifest Document Number. <br /> �J16 <br /> B. State Generator,ID <br /> sc j 4. Generator's Phone ( ' ) <br /> go <br /> 8 5. Trpnsporrer 1 Company Name 6. US EPA ID Number C. State Tran,porte/s ID <br /> ._ D. Transp9 c,s Phone _ <br /> s 7. Transporter 2 Company,Nome 8. US EPA ID Number E. State Tmosporter's ID <br /> Q; <br /> - F. Trampo"'Si Phone ; - <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Store Facility's ID <br /> T-4 O . .. h <br /> LL H. Facility's Phone <br /> U 12. Containers13. Total 74. Unit <br /> !�7 Z 11. US DOT Description(including Proper Shipping Name, Hazard Class,and ID Number) No. <br /> Tye <br /> Quantity.m 14.Wt/Vol I. Waste Number <br /> State). <br /> M/ G EPA[(�Jhen, <br /> ci E <br /> N b. Srore� <br /> E <br /> R - - 6PA/O.then_ <br /> A <br /> O T c. State <br /> Of 0 <br /> a, R EPA/Other <br /> w <br /> d. <br /> Z <br /> Z Sale <br /> W <br /> U EPA/Other <br /> N <br /> Z �r Additional Defs.l lw my s fQr A+aferials Listed Above K. Handling Codes for Wastes Listed Above - <br /> O -,rlurd�o arTh �to at [7 nd i i <br /> N <br /> w <br /> K <br /> Q ,m <br /> Z 15. Special Handling Instructions and Additional Information <br /> a <br /> Z <br /> w <br /> Z <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 /> Qpacked,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 have a 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 currently available to me which minimizes the present and future <br /> a threat to human heahh 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 /> N <br /> waste management method that is available to me and that 1 can afford. <br /> 0 Printed/Typed Name Signature Month Day Year <br /> O <br /> U <br /> Z 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> p <br /> �w ♦ Printed/Typed Name Signature Month Day Year <br /> V N <br /> K I, <br /> W P <br /> 0 18. Trans iter 2 Acknowledgement of Receipt of Materials / <br /> OR Printed/ Nome i r Si gfurs ..., , f _ (Aorp� Dam I Yea/ <br /> w 19. Discrepancy Indication Space <br /> N <br /> F <br /> U <br /> U A <br /> Z I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T/ Printed/Typed Name z- • ..., :�<. -. r r. Signature Month Day Yeo <br /> DO NOT WRITE BELOW THIS LINE. - - <br /> DTSC 8022A (9/93) - White: Tt <br /> EPA 870D-22 `, <br />