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I FormApproved OMB No.2050—�03g(Ezplree 4an-Ol) - p / /� Department of Health Sanic,. <br /> pleal.print or type. .(Form designed for use P (12- itch typewriter). R � d'Q1 � 7 Tozic Substances Control Owls,, <br /> Getor', --ESacramento,Californ. <br /> UNIFORM HAZARDO Generator a us EPA ID Na. <br /> 4: WASTE MANIFEST - Sacramento, <br /> 2. Page 1 Information in the shaded areas <br /> Document No. <br /> 22 of is not required by Federal law. <br /> 3. Generator's Neme antl Meiling Address <br /> ' A. State Manileat Document Number <br /> pUN/I�VEprR`sySAL RUNDLE CORP #97 8 <br /> !- q. GeTera75r4 FfiB(63�g STOCItTON, CA 9"x206 B. State Generetor'el <br /> 0 5. Transporter , Company Name <br /> n 8. US EPA ID Number C. Stela Tranaportera ID <br /> ROMIC CHEM OM C OFWORAYION <br /> N '(•i A [} (p (}m j D Trans"e porter s Phone 7. Transporter 2 Company Neme US EPA ID Number E. State Transporter's ID <br /> F. Transporter a Phone <br /> 9. Designated Facility Name"and Site Atldresa� 10. US EPA ID Number <br /> G. Stale Facility's ID, N< ROMIC CHEMICAL OWPORATION A IJ 0 Q 914151216161 71 <br /> U2W Bay RoW <br /> ..F~Z � FOO AIS. „. SQW H. Facility's Phone <br /> lN1 u f'V0ICL& )191 to A q�. V4-' <br /> C+: �a 11. US DOT Description(including Proper Shipping Name,Hazard Class,end ID Number) 12. Conwners 13. Tot a1 1q, 1 <br /> (�! �(aj a. No. Type OusntltY W'/Vol Waste No, <br /> d c= G State <br /> X'Cb 3 E WASTE ACETONE SOLVENT ( LE LIQUID) ( � � ( y !�`h( C EPA/Other <br /> N - <br /> E b. i <br /> N R <br /> m <br /> T <br /> 6 g $tet` <br /> aR p, ! , f EPA/Other <br /> Ef'�1v7. J 9n/jr r *'F" State <br /> Z <br /> w L9��,� � / state <br /> U <br /> W EPA/Other <br /> = J. Additional Descriptions for Materials Listed Above <br /> O ? K Handling Codes for Wastes Listed Above <br /> w MIXTURE OF ACETONE; CALCIUM SULFATE (FILLER) <br /> ;. b. <br /> `CELLULOSE (FILLER) CALCIUM CARBONATE (FILLER) <br /> a MHKH (HAMNER) a. <br /> Z t <br /> Q15. Spacial Handling Instructions and Additional Information NJ <br /> Z <br /> _ _.. 2 _ <br /> CidoY68, Cgoggie9, artd P01901/0 Goth ',� <br /> hg• (CAUTION—FLAMMABLE <br /> 15 REFER �O ATTACHED M S P! S •., <br /> Li GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> 0. and are government <br /> pecked,marked,and labeled,and are in ell respects in proper condition for Transport by highway acgortlinq to applicable international and <br /> h national government Packed <br /> lmar <br /> If I em a nomarge quantity generator,I certify that I have a program in place to reduce t e volume and toxicity of waste Sane plait o the degree I have determined <br /> O to be economically precticable and theft have-elected the pracliceble method o/ eetmenq storage.or disposal Curren) <br /> Present and future Threat to human health and the environment;OR,if I em smell quantity g P av table to me which minimizes fns <br /> .. 2 generation and select the beat waste management method that is available q y generator,I have ede a good f h effort to minimize my waste <br /> e nAithat I can afford. <br /> OW Printed/Typed Name <br /> x Si tura <br /> HEWIE A POTTS {{ Month Day Year <br /> a �% 'E'1 <br /> W T 17. Transporter f Acknawletlgement of Receipt of Materials <br /> Q A Printed/Typed Nema Siq.a�ur r <br /> N / // Month Day Year <br /> o P . 1 `t('7 .' _!/ / 7f/Sf l( .r(' r',� / : U <br /> N O 15. Transporter 2 Acknowledgement of Receipt of Materiels <br /> \. <br /> U T Printed/Typed Neme Z E Month Day Year <br /> 19. Discrepancy Intlleetlon Space <br /> i <br /> I 20. Facility Owner or Operator Certlflcagon of receipt of hazardous materiels covers by Ihism n feat except ea notatl In I em 191. P) <br /> T <br /> Y Priyntae�d�a/�Typp,e�d Name/asa�ya�rs�� _Signatur <br /> rarz�Rs 1]lliRIMl�I R <br /> L W� PAY aMonth DaY Year <br /> \022A(I/88) <br /> E 08)P2 - Do Not YJ 1 Below This Line Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> 88)Previous editions ere obsolete. <br /> i <br />