Laserfiche WebLink
State of Colifomio—Environmental Protection Agent <br /> For OMS No.2050-0039(Expires 9.30-94) w—Gaw"stEuetlons on back of pr.as b. Department o ox,c u stances Control <br /> Please print or type. Form designed for use on elite(12-pitch)Typewriter. Sacramento,California <br /> 1. Getter�for's US&A ID'Nofy Manifest Document No. 2. Page 1 Information in the shaded areas <br /> S UNIFORM HAZARDOUS j i v.,`_,i is not required by Federal law. <br /> WASTE MANIFEST 1 2 of <br /> 3. Generator's Name and Mailing Address est VWnt Number /� C <br /> o Sumiden Wire Products r ration J v <br /> 11 1412 El Pinal Drive, S on _ c; �.° r' venerator's ID <br /> � I , <br /> 51 <br /> 10 4. Generator's Phone (209) 466--892 '= H �'� ., 3 1 7 5 9 8 <br /> O 5. Transporter 1 Company Name F 6. US EPA ID Numb" 'C:Stare,Tr6nsporter's ID <br /> 00 <br /> Tri State Motor Transi ti <br /> D. Tronsporter's Phone <br /> rirwi8 91918,; 800 742-1671 <br /> -Jr 7. Transporter 2 Company Name 8. US EPA ID Number 'E. State Transporte's'ID <br />,Du - <br /> F, 7ronsporter's Phone <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> V= Chemical Waste Management I nS�/ <br /> �� —1— <br /> 00 35251 Old Skyline Road A H. Facirty'e Phone <br />-fQ C 7000646117 <br />,IU 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br />�Z No. Type Quantity Wt/Vol I. Waste Number <br /> ~ a. State Y81 <br /> 3 GEPA/Other <br /> RCRA HA <br /> E NON- ZARDOUS WASTE SOLID 0 0 ,1 C M 010101114 Y <br /> co N le. State <br /> C0 E <br /> v <br /> � R EPA/Other I <br /> A <br /> 0 T c. State <br /> O <br /> R EPA/Other <br /> LU <br /> Zd. State <br /> W ` <br /> V <br /> LU I EPA/Other �' <br /> U) <br /> Z ;K: HaridGnCod, for:WdifesListed.Above <br /> 0- 7701N- <br /> nn <br /> �USSD, DRAWINGd. <br /> Q � ` <br /> -- <br /> 0 15. Special Handling Instructions and Additional Information 7- /'7[ W3 <br /> Q <br /> Z (HAZ. BULK, DOHS "C" READ) In Event of Emergency g y - Contact <br /> F C.W.M.I. Profile # AJ-1871 CWMI At (205) 652-9221 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> J <br /> pocked,marked,and labeled,and are in all respects in proper condition for transport b highway according too livable federal,state and international laws. <br /> Q Pa Pe P P Wo Y 9 Y g PP• , <br /> U <br /> A. <br /> If 1 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 <br /> economically practicable and that I have selected the practicable method of tr ment,storage,or disposal currently available to me which minimizes the present and future <br /> threat to human health and the environment;OR, if I am a small quantity g ator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste mono ement method that is available to me and that I can afford. <br /> 0 Pri to /Typed Name Sign / fltPnt pay 7or <br /> U <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W A Printed/Typed Name Sig re Month Da Year <br /> 0 t4 <br /> W p <br /> 0 18FTransporter 2 Acknowledgement of Receipt of Materials <br /> W T Printed/Typed Name Signature Month Day Year <br /> LL. E <br /> 0 R <br /> w 19. Discrepancy Indication Space <br /> N <br /> Q F <br /> U A <br /> Z I— <br /> L <br /> 1 20. F«il' Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Pr" ed/Typed Name Signature h Day Year <br /> Y ? % <br /> r <br /> DO NOT WRkE BELO THIS LINE. <br /> Yell TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> (7/92) (Generators who submit hazardous waste for transport out-!!-state <br /> DTSC 8022A . <br /> EPA 87022A produce completed copy of this copy and send to DISC with , ;0 n <br />