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,t1RIIInd Welfare Agency " t' f ! Department of Health Services
<br /> a No.2060--0039(Expires 9.30.91) "'I .: I II Toxic Substances Control Division
<br /> poo. (Fore,designed for use on Wife I -pp�' , ewrffor).' - I. I '. Sacramento,California
<br /> UNIFORM HAZARDOUS 1, Clenerstor s US EPA ID No. ManIf9al P e i'
<br /> I ` � Information In the shaded areas
<br /> ' WASTE MANIFEST C? .� " A n [� G e, �� ITk In not required by Federal law.
<br /> 3. Generator's Name end M 111419 Ad r••• A-State Meni et o u n u b
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<br /> , . r"1 .. 'I�d�eN t.�l'etf�,'.t��ri�r►'Tr7K''��,1 lf�l. I � r._el (���� �L
<br /> y `t ~C35 Stft 4.r;. eL►s -� F,J��� ? f .+"�
<br /> 4. Generators Phone
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<br /> 8. Transporter 1 Compsny.Nome 8, US EPA 10 Number Cr State -,.,-
<br /> A i 1 i rri Petr ;All i'r A e1 tS0 1 iy 171 to I I I Z I lel M Trsneporfers Phone, r1.
<br /> T. Tran ep r 2 Comp ray Ell
<br /> • r+I 8. US EPA ID Number E,-8tste.Transporter'a
<br /> /r' �I � '1 ! .r 1 E i+ ,�In , .I Iy R .-Transporter's PhoNa'-l•� .,,.(<.5.: x a
<br /> 9. Designated Facility Nam•and Site Address II ,10. US EPA iD Number O r Stst•Facility's ID t {.
<br /> AL-i i fieri es Sery i cc ; A.1 p t� h' I ` 8
<br /> l.As;i� ii' ifviY 33 ,I P Ltt?r:;on
<br /> 11,FacilRy ae phone 4 3
<br /> .A ,� t) L7 �? 7 �. tj ��^t rl�lr;l is' ,a a'E':..•�" l e
<br /> j 12. Containers 13. Total 14.
<br /> 11. US DOT Descrlpllor"t eluding Proper Shipping Nam•,Hazard Class,and ID Number) Quantity Unit :"Warts
<br /> No., Type WtrVol
<br /> a. Slate A.
<br /> a ,ATE FUEL' €����c MILE L14ulU I:
<br /> E 10i KA ky`13 . EPA,OtI►er
<br /> E b. I State r7 f ,
<br /> A
<br /> T F,PA/Other
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<br /> j I f EPA/Other {y
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<br /> d Stats w.
<br /> }. EPA/Other:-
<br /> J. Additional Descriptions fo��rpp'Materials Listed!
<br /> �Above I( Handling Codes}or Wastsa-1 isted-Above
<br /> ':.97 1 RATER., ? �j b rr T4s M1 ,
<br /> fr EE t
<br /> 0. •' :�Ir 4y'}:Ch 9fFL lr 1tt �.3 itt4`l;l t'S�k r y S 1 4
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<br /> 16. Special Handling Instructions and.Additional Information
<br /> usyApkupxikiTpk\ rELTiwg. 7L.N1 '4TACT 'Ic1�LCuTEO ►CI.ITY t `i : tCY"CJ (40U)d14-"44.
<br /> ;L,4LKATL1i'.E;l4R,L;LNCY C.L14 ACT t
<br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name
<br /> and are classified.packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable International and
<br /> national government regulatllms.
<br /> It 1 am a large quantity generator.I certify that I have a program In place to reduce the volume,and toxicity'ot waste generated to the degree I have determined
<br /> to be economically praclieeble and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the
<br /> present and future threat to human health and the environment;OR,if 1 am a small quantity generator,I have made a good faith effort to minimize my waste,
<br /> generation and select the bast waste management M01hod that is available to me and that i can afford.
<br /> Pdntad,Typed Name Signature ;;. _ Month Day Year
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<br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials
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<br /> N Printed/Typed Name Sionsture' Jr Month Day Year
<br /> $ ren A1! ...5� !l.��S - tif• ki'�"'T „�:t.� r' .+,-_ .J' I ? e, t
<br /> p18. Transporter 2 Acknowledgement of Receipt of Materials
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<br /> T Printed/Type".M e Signet r,. ,, Month 'pay Year
<br /> E I +'
<br /> 19. Discrepancy Indication Space
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<br /> C I L
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<br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except qs noted In Nem 19.'
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<br /> V Printed/Typed Name, Signature f // Month Day year
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<br /> 9022 A(1108) Do Not Write Below This line.
<br /> 170D-22
<br /> 9-88)Previous editions are obsolete
<br /> GREEN:" HAULER RETAINS
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