Laserfiche WebLink
r <br /> State of CaIVornio'-Environmental Protection Agency <br /> Form Approved-OMB No 2050-0039(Expires 9-30-99) See Instructions on back o e 6. Deportment of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitc;1 ter. 4b Sacramento,California <br /> 1. Generator's US EPA ID No.. Manifest Document Na. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not 1equireci by Federal low <br /> WASTE MANIFEST ,�5 1L ' 1 of <br /> 3 Generator's Name and Mailing Address +{ A. State Manifest Document Number <br /> //trJ1 ' I •fir <br /> 01r955432� �� <br /> 0 0,V e / ",,2 3 B. State Generator's ID �yLO <br /> Ln 4, Generator's Phone 00q) t <br /> CY 5, Transporter I Company Name ! 6, US EPA ID Number C. State Tr sporter'.ti fD Reserved]00 <br /> fY' rR+,rt4 <br /> O 1;7;?/ <br /> r /f — L�Y/�` tf/n �/ !J U G.. D. Transporter's Phann <br /> 000 V 16151 <br /> 7. Transporter 2 Company Nome B.. US EPA ID Number E. State TranspoNers-1D rReserved <br /> ii F. Tronspo"r's Phone. <br /> J Q S r s �' <br /> V 4 Designated Facility Name a d Site <br /> FA/dd�s�s,7/ 10. US EPA 1Q Num <br /> ber G. State Focil• 's ID. t, <br /> + , VIII <br /> r y t' <br /> -Z �, E'���``��I L�l7i'f L r flit r i <br /> C4 t�IV /' l')"rC l �� H. Fs3Ci 's o <br /> J to <br /> 12. Containers 13. Total 1 d-Unit <br /> 11. US DOT Description(inclu&mq Proper Shipping Name,Hazard Class,and ID Number) ' ' <br /> No. Type Quantity Wt/Vol h'Was'te'Number ' <br /> ZO/7'2 l�r Stale <br /> t: - — i�'' ail'" 7. f.✓cw'F 7 `r -t}✓r Cit I r EPA/Other <br /> IG <br /> o N <br /> 00 <br /> co E <br /> v R WARS EPA/C>tfter y <br /> TM <br /> CArr T <br /> c. � lil 1RfMLt1i { rotea�q, <br /> r d <br /> ° �MI�N��I� �DOQN EACrcrrY rrr C EPAfOrherr • , <br /> [d , r <br /> Z PA fiQjJA a, <br /> I[Ila <br /> d _ MITS to REICEIVE YOU HAS THE NECESSARY <br /> V <br /> ��l1 � � � WASTE STREAM A$ EPA/Other:r ; .'» <br /> UR <br /> LU Abo <br /> Z 1: Adds taYy�tlposcnphotis far, riots Usted'Abova �. K. H <br /> # andlin Codas Far Was Ctst <br /> s. -.: xkg, q ' <br /> F;. - X-, 'ytp <br /> ,S �ys$ <br /> LU <br /> 5 <br /> C. <br /> O Ycl <br /> 5. Special Handling Instructions and Additional Info tion = s` -_ J <br /> LLJ <br /> GENERATD S CERTIFICATION: I hereby declare that the contents al this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and nutionol government regulations. <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 economically <br /> Q. practicable and that I have;elected the rodicable method ar treatment,storage,or disposal currently❑.oilable to me whieh minimizes the presen!and future threat to human heahh <br /> en <br /> and the environment;OR, if I pm a small quantity generator, I have made a good Faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> OPrinted/Typed Name ,.� Signature c 1+/ Month 'Day Y ar <br /> V r r 3d� <br /> Z r� <br /> t3.3 T !2cier2Ackno <br /> Transporter I Acknow4cl ement of Recei t of Materials <br /> � R <br /> LIJ A ed Name y - Sig/ y c Month Day Year <br /> sL p 18. Trans D �ed emeo of Receipt of Materials <br /> O T Printed/Typed Name ; -�,. 4gnaCre Month Day Year <br /> LU E <br /> R <br /> a <br /> V F 19. Discrepancy Indication Space <br /> Z A <br /> C <br /> L <br /> 1 20. Facility,Owner or Operator Certification of receipt of hazardous moterials covered by this manifest except as noted in Item 19. <br /> Si opiate- - - -- ` Month Day Year <br /> T Printed/Typed Name g -.- . <br /> It <br /> DO NOT WRITi-9fli THIS-LINE. <br /> - -Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DISC 8022A (1/99] [Generators who submit hazardouswasteFor transport out-of-state. y <br /> EPA 87022A ( p p of this co and send to DTSC within 30 days 1 <br />