Laserfiche WebLink
State of Cefltornlafebllh and Welfare Agency ; AT -. Department W Health Service <br /> Form Approved OMB No.2050--•1039(Expire ) Toxk Substainceaf Control Dfvislc <br /> Please pttnl or tyll (Form designed for use on (I2-pitch lypewthsr�. .;'• 3aonmento,Csllfornl <br /> UNIFORM HAZARDOUS t. Oeeerstors us EPA to No, tdanitea 2. Page t Intonmatlaetni tM shaded areas <br /> Document No. . <br /> WASTE MANIFEST all . In not nqulil by Federal law. <br /> 3, Generator's Naim and Mailing Address <br /> TRY VALLEY #T (Forklift) <br /> . Oenerat "o)#611 Rb Thornton GA 96 <br /> Qt 5. Transporter i Compa., 03 0. US EPA 0 Number <br /> Lo <br /> ryr <br /> to 7 a r y f3. bar <br /> taferatlaporter* i <br /> 9, Designated Facility dame and Site Address 11- US EPA 10 Number ate Facility a ID <br /> J <br /> /L ¢ 51M SALMA BLVD, <br /> o ' <br /> Q 12. Containers t. <br /> 11. US DOT Description(Including Proper Shipping Name,Hazard Glass,and ID Number) Ouantity Unit Waste No, <br /> ti No. Type Wt/vol <br /> fill U a. <br /> State <br /> z <br /> EWAM PETRil XkPg= CMGUSTZ= LIQUIDEPA/Other <br /> ^� E b. g <br /> tV R .. w•. ate- ' <br /> e0 <br /> fvl -i..:- ..... <br /> Q R C. f 'St• >s•. <br /> HIM EPI <br /> d. P3 <br /> Sta <br /> LU <br /> JIFA/0iher , <br /> to <br /> on J. Additional Descripltons for Materials Listed Above <br /> y K. Handling Codes for Wastes Listed Abort <br /> O a. b y'-T '41 +spa <br /> ff 4 <br /> C d1ttik•.. :. <br /> F_ 15. Special Handling Instructions and Additional Information <br /> 4 <br /> Z <br /> Lu <br /> mac RESP . 1-748497--UW (a 14W-M 4664 (24HR) 7-185-01-4453 <br /> TRUCK PER DAY SK =* As 501 B : 627965 <br /> LOWQ <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 are classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> d national government regulations. <br /> It I am a large quantity generator,l certity,that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined <br /> C 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 heallh and the environment;OR, it I am a small quantity generator,I have made a good faith effort to minimize my weals <br /> Q generation and select lhl beat Masle management method that is available to ril and that I can <br /> Z / <br /> 0Lu Primed%Typed Name Signaidr Month Day Year j <br /> Lj <br /> W T 17. Transporter !,Acknowledgement of Receipt of Materials L, T r SIP, <br /> H <br /> Z A Printed:Typed Name Signature a N g Month Day ear <br /> o a n n G r <br /> U.1 C 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> r] <br /> a P Printev'ryped Name Si nature <br /> U T g Month Day Year <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> 1 20. Facihly Owner or Operator Certificatron of receipt of hazardous materials covered by this manifest except as noted in Item 79. <br /> T <br /> y Printed+Typed Name Signature Month Day Year <br /> Clark F . <br /> OHS 8022 A(I,88) Do Not Write Below This Line <br /> EPA 87022 <br /> (Rev. 9.88) Previous editions are obsolete. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITuIN 1-0 DAYS <br />