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Stan m Cslddrn,e--.teeilh an6 Ws+tars Agency _ $99 {RStf[lCttOnB On �8 Pa99 6 _ Deosrtment of Health Services <br /> =orm ADproved OMB No 2050--0039(Expires a-30 oz,c Suoatancas Lontra Diwa,an <br /> ane Front of Pag9 / aacrameata Caidomie <br /> ?teras Anne or type Form designed for use as elite(12 a+retr fvpetrrrreN <br /> rr UNIFORM HAZARDOUS ' _ Generator a US EPA 10 No Mandeat - page t lnfomnauan m 1110 anaded areas <br /> WASTE MANIFEST I ,. I n p 1' J t� Yu1eni -1 <br /> r of is not required by Federal law <br /> A State L'landow Document Number <br /> 3 Generator a Neme ane Mailing Aapresa y�e� 1 � +' <br /> y J <br /> 1 J Ci j r,a r 1 B State Generilors tD <br /> ♦ Generators Phone(Rjj, <br /> O t 5 1 rensooner t Company Nam* 6 US EPA tD Number C State Tnlrapalars ID Z <br /> v'n i t I 14 I , I^ D TransPoners Phan* ! 7 <br /> ' I I 7 Transporter 2 Company Name 8 US EPA ID Numoer E state Transporter s tD <br /> m <br /> 0 F Trsnepartars Phone <br /> 0 <br /> 4D9 Designated Facility Name and Site Address 10 US EPA ID Number G. State Faatlltr'a m <br /> I <br /> Q I ;riCkSOiI. II:C. K Fscimwe Phare <br /> '"sr— lVd. <br /> zt <br /> 2 Contelrters I 13 Tot1!< <br /> O 11 US DOT Descnption(Including Proper Shipping Nam* Hazard Class and ID Number) I Quantity I Unit Waate►fo <br /> LL No I Type Wt/Vol <br /> 1 �I Stan <br /> L) " 'yes[$ =r�bty �torate '�nK I S <br /> 1 2 G f I EPAfOU <br /> L.w = 11 0 <br /> E b I I �i Slate <br /> -111014 <br /> N R i <br /> A E EPA,Othw <br /> m T <br /> 0 State <br /> Q R <br /> m <br /> EPA/011ier <br /> w d i State <br /> U <br /> Z ! EPA/Otltar <br /> ai J Atkkfjg nal DMa4nwte tdr tMbulals L law Aboveb. <br /> K tiraAlitq 6pdes for whit«Lleled Above <br /> 7tv. EMPty ytcraga Tank (s) �fig. <br /> aWc Tach (a) have bort inertad with LS lbs. a <br /> a Dry Lcet €er LOCO Gat. Capacity. <br /> Zr 15 Special Handling Instructions and Adartrona+information <br /> Q <br /> Z <br /> leeP aw&v from sources )t 1>gnation, klways .rear zarahacs +hen +orking arouro <br /> i= l.b.s. 's 24 ir. Contact •ame : 'hone _ <br /> J <br /> GENERATOR S CERTMCAT1OW I hereby declare that the tomenta of this consignment ars fully and accurately described above Ov proper snipping nems <br /> and are cfaaadned packed marked and labeled and are in all respects in proper conartton for transport by highway according to aopucable International And <br /> national government regWatrdna <br /> It I am a largo quardity,genwelor I certlty that I have a program in place to reduce the volume and toxtcdv of waste generated to the degree f have determined <br /> Q to be econdrtnICA11W praditrrable and that I have selected the practicable method of treatment atorape or disposal currently available to rine rvnrdh mmrmrtee the <br /> O weaent and future threat to human health and the*mltronmem OR It I am a email quamlty generator I have made a good tenth Alton to minimae my waste <br /> } generation and select the beat waste management method that is available to me aria that I can afford <br /> C1 <br /> WPrnrted/Typed Name Stgnature Month Day Year <br /> � _ <br /> W . L. <br /> WT 17 Transporter t Acknowtodgaersprl of Receipt at Materials <br /> C A Primed ITyped Name r Signature f Month Day Year <br /> LL S <br /> O P <br /> W D 18 Trantttorier 2 AcknpededgearerK at Reeerpt of Materinly <br /> C <br /> R PrintedlTyped Name Signature MdnM OeY Year <br /> U T <br /> _ E <br /> 19 Dfaereparwy Irndiatlide Specs <br /> F <br /> A <br /> C <br /> 6 . I <br /> L <br /> I Za Facility Ceor Operatlx Cerhazardousrnale ton of receipt Of hazardous matecovered by this manifest except as noted in Item 19 <br /> T Sigrrattae Mono pay Year <br /> y Pr4ded I Typed Name <br /> oris <br /> 8022A Do Not Write Below This Line <br /> I EPA 870D-22 <br /> (Rev e-e9)Printout edMose are 0600WO <br /> YELLOW GENERATOR RETAINS <br />