CO0015375 - Laserfiche WebLink

Home Browse Search

;tate,pf CaVorni ppvironrgental Protection Agency orm-P MB 1N .2050-0039�(Expires 9.30-99) See Instructions on back of page 6. 'lease print or type. Form designed for use on elite(12-pitch)typewriter. P g Department of Toxic Substances Control Sacramento,California UNIFORM HAZARDOUS 1. Generator's US PAID No. Manifest Document No. 2. Page 1 Information in the shaded areas WASTE MANIFEST _ is not required by Federal law. i 1< Lf of -- F1 ,3; GenerQtar's Name and Mailing Address i A. State Manifest Document Number 20244787 j jo,a,,'Xyi/ � B. State Generator's ID 4. Generator's Phone.( ) 3 �> 5. Transporter 1 Company Nome 6.VTEPA ID Number C. State Transportar's IQ(Reserved.] � !X>fr:. ��, L{J� •� /"r ;li 1 �1 , ! ) - D. Transporter' Phone Sys-� 7. Transporter r2• omypany Name 8. US EPA ID umber E. State Transporter's I -(Reserved. J"Gl-J f' i �5 ZJ l•�'ll �i /s jj, -JD ) •� J ]_ F. Transporter's e3/. ] '. ' 9. Desi noted Facility Name and Sit Address 10. US EPA ID Number G. State Facility's ID -G tK['.1 ',t eit l�u �J t✓ trS r {o•��1 H. Facility's hone 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) 12. Containers 13. T41 14. Unit j f y No. Type Quantity Wt/Vol 1. Waste Number. ��a.. ✓'yy � �G ,;�r State w_:lJ�f:' }} E b' A144 V K�:�t?I=� � u/C-t✓Ci�j CiiGrS ti ��, fl✓ State.s S� A -4-24,3 L! r Kit), f_" T EPA /Other C. State j ° i HIS WASTE STREAM HAS B EN QUALIFIED EPA/Other d 1 G . ENVIRONM.,ENTAL FACILITY IN LO ANGE State CHIS FACILITY ATE NE ES EPA/Other J. Additional Descriptions for Materials Listed Above t 't'"'i�' ��VLr tGp 'Ivs .5G7�t�IG -� oi,- f V iT9 Codes.For Wastes Listed Above \\ , Ili�Q�A'�► I t3 0{1R EPA NUM2ER IS CA ®8003' b. d. L:r 15, Special Handling Igstruc ions and Addity�nal Information °Wr j ✓tr Ic Yn:,tuD",r j f tr•�� r��L A/L/ 38 o L ( fr- �73 k", C ! 16. GENERATOR'S CERTIFIC TION: I here6y declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. 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 economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me 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 effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. Printed/Typed Name - Signatu / Month Day Year no/-., � loll 1015- 1011 T 1 . Trans orter 1 Acknowled ement of Rece, t of Materials R N Printed/Typed Nome r Signature /! ' / /j J�' Month Day Year S e D 18. Transporter 2 AclVowledQement of Receipt df Materials R Printed/Typed edgN ':' r� 'iT ypSignature Month Day.- YearB K 10 0 F 19. Discreprfncy Indication Space I' A C 1 I , L I 20.-Foplity Owner or Operator Certification of receipt of hazardous materials covered by this manifest PCcehas not in1fem'19, T Printe /Ty ed araeSignature` c I` _ 1 nth;s /f,lay lse�ar DO NOT WRITE BELOW THIS LINE. -_- Yellow, TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. SC 8022A (1/99) (Generators who submit ha ordous waste for transport out-of-state, 4 8700-22 produce completed copy of this copy and send to DTSC withio.30 days.)