Laserfiche WebLink
State of California—Environmental Protection Agency <br /> Form Approved OMIT No 2050-0039(Expires 9 30 99) See Instructions on back of page G Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite(i2 pitch)fyp <br /> ewn ter Sacramento California <br /> r1 1 Generator s US EPA ID No Momfesl Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal low <br /> WASTE MANIFEST {R x } �� f /' i { of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number 248.17229 <br /> � 7C� t fie",14'- ':"' S State Generator s ID <br /> A Generator s Phone ('; F 579,—( $ �tl i�{ i'�'1 1 ` <br /> I to <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved I <br /> to <br /> m - a D Transporters Phana � <br /> 7 Transporter Company Nome 8 US EPA ID Number E State Transporter s I Reserved <br />�}J F Transporter s Phone <br /> �Q <br /> V 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Faulity's ID w <br /> tr { CA 011 <br /> Z o H Facility s Phone <br /> J <br /> a-' 7GIV t. tlt Y+3 ` t 1 F t 'r y ♦ 5. � .? (� <br /> 12 Containers— 1 Total 14 Unit <br /> Ui 1 US DOT Description(including Proper Shipping Name Hazard Class and ID Numbed No Ty a Quantity Wt/Yol I Waste Number <br /> a ` State <br /> SS. <br /> EPA/Other <br />' E State o N b <br /> 0 E EPA/Other <br /> V <br /> V A c State <br />' m 0 EPA/Ocher <br /> R <br /> LU d State <br />' Z FPA/Other <br /> LUV <br /> W <br /> 'n J Additional Descriptions For Materials Listed Above K Handling Codes for Wastes Listed Above <br /> Z a _ b <br />' C } d <br /> Z 15 Special Handling Instructions and Additional Information 3a r <br /> 0 p g t� �i� W� hie. Fe°�`< -3 <br /> �1SJ Yi'C`f 1{a'r't If 41,ki <br /> Z <br /> LU <br />' 16 GENERATOR S CERTIFICAVON I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed <br /> Q marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and nationol government regulations <br /> IfsI om a large quaniiy generator I certify That I Bove o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> CL practicable and that I hove selected the practicable method of treatment storage or disposal currently avorlable to me which minimizes the present and future threat to human health <br /> and the environment OR if I am a small quantity generator I have made a good Forth effort to minimize Ty waste generation and select the best waste management method that is <br /> ae available to me and that I can afford t <br /> O month Day Year <br /> Printed/Typed Name Signature <br /> V <br /> ZLU <br /> r <br /> 0 17 Transporter 1 Acknowled ement of Receipt of Materials <br /> !t Pryrted/Typed Name f r <br /> SignoTu}e; Month Day Year <br /> Ze <br /> LU S Ir� l ]t_- "".� z a <br /> r � � . <br /> i.c. 0 18 Transporter 2 AckrTi9+wled errant of Receipt of Materials r <br /> / �r Month Day Year <br /> Q i Panted/Typ erre r �S Signature � � f g� <br /> Q R f s�Sr Z <br /> V 19 Discrepancylndication Space <br /> Z F <br /> A <br /> C <br /> I <br /> ( 20 Facile Qwner or Operator Certificohon of recei t of hazardous matenols covered b this man sT ce t as note m)tem 19 Month Da�_ Year <br /> Y Printed/Typed Napre'y �j �/dy Signaturef�r, <br /> fir" f '"` .... <br /> ��.. rr f���� 'cam <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN'M DAYS <br /> (Generators who submit hazardous waste for transport out of state <br /> produce completed copy of this copy and send to DTSC within 30 days 1 <br />