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TEXAS NATURAL RESOURCE <br /> CONSERVATION COMMISSION ` ✓ <br /> P.O.Box 13087 r �, <br /> Austin,Texas 78711-3087 <br /> Form approved.OMB No.2050-0039. <br /> please print or type.(Form designed for use on alae(12-pitch)typewriter.) Manifest 2.Pae 1 <br /> UNIFORM HAZARDOUS 1.Generators US EPA ID No. �g 9 Information r the shaded areas <br /> "WASTE MANIFEST i <q °' of snot required by Federal law. <br /> 3.Generators Naptearfd:Mailing Address HELENA %H M L A Statp Manifest Doturn dmrj <br /> 2245 W CHARTER WAY S 93, <br /> `' <br /> ATTN WAYNE MITSUDA �.2 35201 acen utor:,l0 <br /> STOCKTON ;e <br /> 4.Gene es <br /> Phone 209 465—`x777 <br /> 6. US EPA ID Number Tran`,crr-tars 800 6 <br /> 5.Transporter 1 Company Name ansport r s r'hone:.`3"0 Et�'r`> �i -77 <br /> SAFETY–KLEEN SYSTEMS, INC S.CR00007.51S0 — <br /> 7.Transporter 2 Company Name 8. US EPA ID Number E State:Tra ispdrfer'siID _ <br /> '_fransport:rs one <br /> 9.Desi "led Facility Name and Site Address00061 10. US EPA ID Number .$tatq.FaGll ty,ID <br /> SAFirTY–KLEEN SYSTEMS, INC- <br /> 11'22 <br /> I — <br /> 17'22 COOPER CREEK ROAD = , <br /> DENTON, TX 762081-1 1 <br /> 13, <br /> 12.Containers 14 I <br /> 11 A; 11.US DOT Description(including Proper Shipping Name,Hazard Class,ID No. Type Total Quantl W nit Neste No. <br /> Him Number and Packing Group) <br /> a. HAZARDOUS WASTE, SOLID, N. D0, S. Q <br /> o X (,CHROMIUM) _ 9 NA3077 PG III ( ERG#171 ) 0.t7 M V.f ,3 .2. <br /> E <br /> N C I <br /> R b. NOW RCRA HAZARDOUS WASTE SOLID � � 0.070 <br /> 7 0 J P <br /> A <br /> T <br /> 0 <br /> R c. <br /> J. <br /> r <br /> 15.Special Handling Instructions and Additional lnfortnation yy MFST R/T 101376067 000.2-3821-62 <br /> EMECORNCYY RESPTH'D 800-4S8SUBSOSGIJENSRte�RRFERSAE�I13pd 4iL1E355��ZRC1Z15�40582E84815 <br /> SK SKDOT# A: 22256 Ei: 23107 Cc D: <br /> 16.GENERATOR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name end 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 /> If I am a large quantity generator,I certify that I 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 tome and that I can afford. "' , '`'. .^ Month Day Year <br /> Pri ,yped Names, Signanne , , r i /�f 0 7 4 10 1 <br /> -`} ',... Date - <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials ! Month Day Year <br /> R Signature Z 1 d7. <br /> A <br /> P-rimed/Typed Na •.� .., ..k..,.._-,.....^^.. .X <br /> N ^/ 1�4V!> /�i `J'M '"�6�„" Date <br /> 0 18.Transporter 2 Acknowledgement of Receipt of Materials Month Day Yea. <br /> R Printed/Typed Name Signature <br /> E <br /> R <br /> 19.Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item Date <br /> T <br /> Yea <br /> y Signature Month Day <br /> Printed/Typed Name <br /> p!�,cAa r i Pink-TSD Facility Yellow-Transporter Green-Generators first copy <br /> TN'Y'i�`„r��(�I°)� ��.L 481c.; � a aou��`�.s. �� __ _._.--__ — <br />