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JRN 11 ' 89 10:55 P. 02 spartmont of Health Smites <br /> •r'es rP r� Vf WG tram dosipxd br use on eine cn typewr/Nr). �nStrllCjld on C'( T"ic Substances Control Diviann <br /> _� <br /> MF IR HA7.A�i 5eaamenra,calnanie <br /> �O 1. 001"S US EPA Ip No. Manifest 21 Peps 1 <br /> WAS MANIFEST�k Document No, Inle maria m the shaded Iran. <br /> 9f Is not required by Federal 4w. <br /> 2. G rotor's Name and Mailing AedrNa A. SqN Maniast Document Number <br /> f , <br /> ,-a. Sprint CDaetunication V30 Old nay shote M at. 300 <br /> Pnrzia arae <br /> 4. Genmeta�a Phone ICA 94010 Attenti Joel let Clair S. 9tue Generaieve m <br /> lilt-A]Ar <br /> Np Transporter 1 Company Name e. US EPA ID Number C. State Tr.napater's ID <br /> al <br /> ry '2 ' D. Trareporter's Phone <br /> T Tra^ <br /> 411IMOr 2 Company Name 9. US EPA ID Number E. Seta Trenspneer's M gig &%rr ages <br /> F. Trinep9rter'a Phone <br /> B. Dealpnated Fecdily Name and Site Aildross 10, US EPA ID Number G. Stats Facility's Ip <br /> K %finery Services <br /> 13331 N, flighv" 33 H. FaCdty'aPhone <br /> z <br /> 11. US DOT poaCri Goes(including PIPGF SPI 12. CAnNirmro 13. Total 7wu,,r4vtl <br /> P 9 P ppinp Name,Mazard CNa4 and ID Number) No. T • Quantity Weele No. <br /> m <br /> Z O Stile <br /> E -- <br /> � N <br /> EPAMne <br /> E o. <br /> rvp N State <br /> SI A <br /> 7 EPArOtRtir <br /> i 0 <br /> Suu " <br /> A/O1M <br /> tl <br /> State <br /> u <br /> RPA/Omar <br /> [ J. Au" <br /> nlonal Deeaiptias for Materials Listed Above K. Msntlllnp Codes ter WaNes Listed Above <br /> J <br /> 3; Ciesal/water/Riassaid a OR-1 b. <br /> c <br /> .voW Monolog Instructions and Additional Information <br /> Wear Cl(MS <br /> i GENERATOR'S CERTIFICATION: I hereby demure mat the contents of this conefpnma It are fully and accurately described above by proper shippirq name <br /> ono ere clas"Ifd,packed,melted,and labeled,and are In all respects in proper condition for transport by highway according to applicable Intemadona,8,V <br /> e <br /> national ga. mmeat regulations, i <br /> 11 I am o large quantity 9anarata.I cerdty that 1 hove a program In place to reduce the volume and toxicity of waste generated to the degree I have determined <br /> to be eea,Omieaay practicable and that I have selected me practicable method or treatment.Storage,a disposal currently avalleme 10 mti which mmknitae the <br /> Praiser Red future threat to human health and me enviromfro itl OR,II I set A smelt quantity generator.I never made a pond faith effort to mmfmi=e my waste <br /> i generation and select the beat waste management method that is available to me and that I can afford. <br /> Phmed Ryped Name Signature MonfR Day Year <br /> i� <br /> i R 17. Transporter 1 Acknowled9emem of Receipt of Materials <br /> iN Printed,Typed Nemo Slgnatwti Almon Day Year <br /> i, o <br /> !! D Id. Transporter 2 Acknowledgement of Recept of Msteriale <br /> ii R Prmted/iyped Name <br /> i E 819nstuq Month Day Year <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L > <br /> R. FeclMy Owner or Operator Cenitic.tion of receipt of hazardous materials 9averad by this maPofest except as Rettig In dem t5. <br /> Y Pnnlad/Typed Nem1 <br /> Signature MpnrA DIY Year <br /> y i <br /> IS 9022 AW") Do Not Write Below Thi&l�he GREEN; HAULER RETAINS <br /> 'A 97011-22 r <br /> ev 9.96)Prevloua edilgee are obaolere <br /> I y <br /> Ss.AP'_1 <br />