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TEXAS DOMMISSION ON <br /> ENVIRONMENTAL QUALITY <br /> P.O. Box 13087 <br /> Austin,Texas 78711-3087 <br /> Please print or type.(Form designed for use on elite(12-pdch)type.—.c1 Form Approved. OMB No.2050-0039. <br /> UNIFORM HAZARDOUS t.Generate,,US EPA ID No. Manifest 2.Page 1 nformation in the shaded areas <br /> 0 ' ment No. of is not required by Federal law. <br /> WASTE MANIFEST -• - <br /> 3.Generator's Name and Mailing Address - A.State Manifest Document Number <br /> S 04 2 ; —ss_ 2 <br /> B.,State Generator's ID <br /> 4.Generator's Phone <br /> 5.Transporter 1 Company Name 6. US EPA ID Number C.State Transporters ID <br /> D.Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number E.State Transporters ID <br /> F.Transporter's Phone <br /> 9.Designated Faciliiy�Name and$its{yddress ;j, 10. US EPA ID Number G.State ycility ID <br /> H. Facility's Phone <br /> 11A. 11.US DOT Description(including Proper Shipping Name,Hazard Class,ID 12.Containers 13. 14. I. <br /> HM Number and Packing Group) No. type TOtd unit Waste No. <br /> Quantity WtVol <br /> a. <br /> E <br /> N <br /> E b. <br /> R J <br /> O <br /> R C. c <br /> d. <br /> J.;Additional Descriptions for Materials Listed Abo =i K:Handling Codes for Wastes Listed Above <br /> 15. Special Handling Instructions and Additional Information r,h <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are <br /> classified,packed,marked,and labelled/placarded,and are in all respects in proper condition for transport by highway according to applicable international and national <br /> government regulations,including applicable state regulations. <br /> It I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and <br /> future threat to human health and the environment;OR, If I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select <br /> the best waste management method that is available to me and that I can afford. <br /> Printed/Typed Name Signature - Month Day Year <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R <br /> A Printed/Typed Name Signature Month Day Year <br /> N <br /> P <br /> a 18.Transporter 2 Acknowledgement or Receipt of Materials - Date <br /> T Printed/Typed Name Signature Month Day Year <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> c 2q.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br /> I <br /> T <br /> y Date <br /> Printed/Typed Name Signature Month Day Year <br /> TCEQ-0311(REV09/01/02) White-original Pink-TSD Facility Yellow-Transporter Green-Generators first copy <br />