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VIP <br /> .,TEXAS WATER COMMISSION /— _d.5 +t <br /> P.O. Box 13087, Capitol Station c o <br /> Austin, Texas 78711.3087 <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS Form Approved.OMB No.20500039 Expires 91094 <br /> 1. Generator's US EPA ID No. Manifest Document No. <br /> WASTE MANIFEST 2. Page 1 Information in the shaded areas <br /> + is not required by Federal law. <br /> 3. Generator's Name and Mailing Address - � -,.,, of <br /> A. State Manifest Document Number <br /> 697953 <br /> 4. Generator's Phone( 09 ) 44 05,i B. State Generator's ID <br /> J �3`AJtI <br /> 6. Transporter 1 Company Name 8. US EPA ID Number <br /> C. State Transporter's ID <br /> L u g d 4 9 C 6 2 6 2 'D: . Transporter's Phone i; <br /> 7. Transporter 2 Company Name 8. US EPA ID Number -E: State Trans orter's ID <br /> F. Transporter's.Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G, State Facility's 10- <br /> :;AF::TY—KLE4h: C.IIiF . 8—LCo— Iof <br /> .i 722 COLPcA l;mc.:. R AOA <br /> H. Facility's Phone. <br /> ucrY 1GN TA 7u.;,Jtl TSu 077aY;;:] li rs 17 3.1 ,— <br /> fi h. 4 a <br /> 11. US DOT Description(including Proper Shipping Name, Hazard Class and/D Number) 12• Containers T13.otal 14. I. <br /> G HM, Unit Waste No. <br /> E a. I I No. Type Quanti Wt/Vol <br /> 17 <br /> MS} <br /> T b. <br /> 131,f <br /> C. <br /> d. <br /> J. Additional Descriptions for Materials Listed Above <br /> K. Handling Codas for Wastes Listed Above <br /> t1?. 23f!,Yl,-5D001 t�1 'Ila. <br /> '_7.223, 7)01 r <br /> 15. Special Handling Instructions and Additional Information ir. ay - <br /> 7—ids—Ui— ?11 FF 4— 11:.,;NRPu 271401i/C,1?0;;3�—J <br /> -11IAESPp70d—t988-46OC '4Nei .0 TLi1 J Jr.'-+ y. r1 1 i .. . -4'13-2 <br /> FCR RECYCLE SKDUTA Al 000300: 3001331 C: <br /> 16. GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by a <br /> packed,marked,and labeled,and are In all respects in proper condition for transport by highway according to applicable International and national)g government regular ons, <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 <br /> determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me <br /> which minimizes the present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith <br /> effort to minimize my waste generation and select the best waste management method that Is available to me and that I can Afford Me Date <br /> _�Printeq ped Na a Si nature ' <br /> rk/k 1�/GNoI,$Url/ �� i Month Day , Year <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> N �_prin edjTyped Narrie Date <br /> Signature —7; Month Da <br /> s / .r v! ijIl e ` t y — Y Year <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials r `J <br /> Date <br /> T PrintedlTyped Name Signature <br /> E <br /> R Month Day Year <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> I <br /> T 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature <br /> Month Day Year <br /> EPA Pone 8780.22(Rev.9-88)Previous edition is obsol White-original Pink-TSD Facility Yellow-Fra r Green-Generator's first copy <br /> TWC-0311 (Rev.01/01/89) 1 x CL 13 <br />