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Slate of Celilornle- Heauff and Welfare Agencyr ln! �.; gr) i ' - � ,. I Department of Health Service.Form gpbroved OMB No. 2050039 (Expires 930.91) T( Ic Substances Control Division <br />Please winl or tvaa. /Fnrm H..i—A 1—... 'Iild [ '.I yr ,y�/9'( pz <br />y <br />^A STOP -22 <br />env. 9-88) Previous editions are obsolete. <br />Do Not Write Below This Line <br />'.:hila -DF ;I 1111 <br />OP'i In [;OH' 'I IN 20 Dqo, <br />'in. .rap. .412 <br />YNIFONM HAZARDOUS <br />1. Gamer.US EPA ID No. at <br />2. Pe <br />r -T <br />WASTE MANIFEST <br />a an <br />/Q D'01oc ant N . <br />Information In the shaded areas <br />of If <br />Is not required by Federal few. <br />3. Ge ii v aped M9111n0Addrep <br />A. 81e1e MlnK�at j1oP�Wngntliurpbsi O <br />9 216 <br />N3.5SC1 C �tt 5/00 kA1�l ��v Q <br />6 <br />B. Stele aYsaralor''sIDD <br />, l <br />a. Generator's Phone K ) A <br />s <br />5. Transporter t Company Ne <br />e ( e. US EPA 13 Number <br />C. State Transporters ID <br />1 L/ <br />II// <br />LA I! N N O <br />. Transporter's Phame *YZ� a <br />j <br />] Transporter 2 Company Name B. US EPA ID Number <br />E.;81ate Traneponer'a m <br />. TNtJprxlaY Phone <br />9. Designated Facility Name and Site Address 10, US EPA ID Number <br />0. Z)(ate Facluty's ID <br />Erickson, Inc. <br />) <br />255 Parr Blvd. <br />H.Feetwty Phone <br />c <br />i <br />t t. US DOT Description (Including Proper Shipping Name, Hazard Claes, and ID Number) <br />12. Contelners <br />13. Total <br />Quantity <br />I4. <br />Unit <br />I. <br />WdeNAox <br />! <br />No. Type <br />Wt/Vol <br />a. W Ste Empty Storage Tank AMI A55Dtf uA-k � <br />lata 512 <br />EPA/Other <br />FIrpf99� <br />N <br />0 <br />E <br />i n <br />b <br />NGNE <br />State <br />A <br />EPA/Other <br />O <br />tt <br />o. <br />`• <br />Siete <br />E A/Other <br />d <br />tele <br />EPA/Other <br />J. Additional Descriptions for Malarial! Listed Above K. Handling Codes for Wastes Listed Above <br />p°Kt e. b. <br />Qty. Empty Storage Tank (a) <br />Tank (s) have bean, liteft d <br />Dry Ice per iobO Gall. Capacity: } <br />f <br />15 Special Handling Instructions and Additional Information <br />Keep away from sources of ignition. Always wear hardhats when working around <br />U,S.T.rs <br />1s <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, pecked, marked, and labeled, and are In all respects In for <br />proper condition transport by highway ecdording to applicable International and <br />national government regulations. <br />If I am a large quantity generator, f certify that I have a program In place to reduce the volume and toxicity of waste generated to the degree I have determined <br />10 be economically practicable and that I have <br />selected the practicable method of treatment, storage, or dispoa I currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, if 1 em a small quantity g nerelor, I e a e faith effort to minimize my waste <br />generation and select the beat wsale management method that ie eve able to a and th I n afford. <br />Printed/Typed Name Signator Month Day Year <br />.k c <br />1). 1rensponer 1 Acknowledgement of Receipt of Materials <br />7 <br />R <br />A <br />N <br />Primed/ tl Neme <br />l/ <br />Slgnatur _ Month DayYear <br />0 <br />R <br />I8. Transporfer 2 Acknowledgement of Receipt of 7tenals <br />PrinledlTyped Name <br />Signature Month Day Year <br />E <br />19 Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />Facility Owner orOperator Certification of receiptof hazardous materiels covers h manliest exc <br />LT20. <br />tetl/Typetl N me <br />Slgnel Monfh Dey Year <br />` <br />y <br />^A STOP -22 <br />env. 9-88) Previous editions are obsolete. <br />Do Not Write Below This Line <br />'.:hila -DF ;I 1111 <br />OP'i In [;OH' 'I IN 20 Dqo, <br />'in. .rap. .412 <br />