Laserfiche WebLink
and Welfare Agency Department of Health Services <br /> Star..1 Cebor�l.-:Hfulllh <br /> Form Approved OMD No.2060--0039(Expires 9 30 91) Toxic Substances Control Division <br /> Please print or type. (Form designed for use on e0 -pitch typewriter). Sacramento.California <br /> r UNIFORM HAZARDOUS US EPA ID No. Manifest2. Page + Information in the shaded areas <br /> WASTE MANIFEST Document No. <br /> i <br /> � r U / ai is not required by Federal law. <br /> 3. Generator's Name and Meiling Address A. State Manifest Document Number <br /> G/) /U,*lCf B. State Generator's ID <br /> 4. Generator's Phone ) 4/ <br /> B.,joinspoAT <br /> 8. I.I.S.E Ve/DyLlm C. StateT'ransporter's•ID <br /> a. / D. Transporter's Phone „ <br /> N -L 1177 <br /> 7. Transporter 2 Company Name e. US EPA ID Number E. State Trunspor ei s ID <br /> 0o F. Tninaportar'.v Phone <br /> 00 <br /> 9, nat«no Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> JX1 51"jo' e."v7ce Go L_I�LL <br /> „r aC �a,3 • S� S `' UA H. FacilltY's Phone <br /> 2 ' 12. Containers 13. Total 14. I. <br /> 110 11. US DOT Description(Including Proper Shipping Name,Hazard Claes,and ID Number) Quantity Unit Waste No. <br /> No. I Type Wt/Vol <br /> e. LC,Z J. fes_ C l / Stele <br /> Z ,/ / qy <br /> E 4 �,✓. (�I '^r ) /V } �_ V!� EPA/Olher <br /> N E Is. i Stele <br /> of R <br /> 0) T EPA/Other <br /> V O <br /> N R c. State <br /> d) <br /> m EPA/Other <br /> W d. State <br /> 2 <br /> U <br /> EPA/Other <br /> w <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> O <br /> e. / b. <br /> C. d. <br /> cc <br /> Z li / <br /> o ,irc o' C�i�c ems/ <br /> F 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z / <br /> Q 18. <br /> U <br /> and are <br /> GENERATOR'S CERTIFICATION: I Ind lab declare that the contents of this openconsignmentomniare fully and accurately described above pl proper terrane name <br /> 0. and are government <br /> pecked,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 /> V <br /> 0 If I em a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the o m ea I have determined <br /> U present <br /> economically practicable and that have selected the practicable method of(quantity g storage,or disposal currently faith ha to me which minimizesatthe <br /> � present end tutors threat to human health and the environment;OR,if I am a smell quantity ganeretor.I have made a good faith etlort to minimize my waste <br /> U generation and select the best waste management method that is available to mea 1 I can afford. <br /> WPrinted/Typed Signet Month Day Year <br /> W /C,,00`1 C4 ✓ L-S'a V �j <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z R <br /> Q A Pri Typed/'Nama Month Day Year <br /> U- s 1 G / G <br /> P <br /> W 018. Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> U R Printed/Typed Name Signature Monlh Day Year <br /> E <br /> Z_ <br /> 19. Discrepancy Indication Space <br /> F 11Tp1-a `II'11�f/11�1 <br /> A <br /> C <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous al w Brad by this manileel except as noted in(tent 19. <br /> T <br /> y Printed/Typed Name Si A���r t, IJH Month Day Year <br /> ENb11.01 ti° VICFS <br /> DNS 8022 A(1/88) Do Not Write Below This Line <br /> (Raves 68)P evioua editions are obsolete. Blue: GENERATOR,SENDS THIS COPY TO DOHS WITHIN 30 DAYS <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br />