|
i
<br /> State of Cohlo,mo---Environmental Protection Agency
<br /> Form Approved OMB No 2050-W39(Expires 9 30 99) See Instructions on back of page 6. Department of Toxic Substances Control
<br /> Please print or type Form dopgned For use on elite(12 pitch)yp r Sacramento California
<br /> UNIFORM HAZARDOUS 1 afor's US EPA ID No Manifest Document No 2 Page I Information in the shaded areas
<br /> f is not required by Federal law
<br /> WASTE MANIFEST L, (� 14171 O 01 (,� of
<br />' 3 Gonerafor'ii Name and Mailing Address r t 1\/ ` j/ -yam �A'r $Fa�ns�fq p s!}�t m
<br /> 6L
<br />'n 4 Generators Phone 01
<br /> CV 5 Tronsporter 1 Company Name 6 US EPA ID Nbmber ` ,?'S}19 gsWPLpg�ryr,' }f,?)�ft se °d{:°�'
<br /> Wo AMERICAN1!#iI.1.0 Y WASTE OIL v A E 0 0 0 8 2 7 $ T $ Ka
<br />' ao
<br /> 7 Transporter 2 Company Name 0 US EPA ID Number ' =7
<br /> v
<br /> i 10 US EPA ID Number . )4 i x I r e v -
<br /> z 5300 CLAUS ROAD Q � Wo�
<br />.{ O RIVERUNK CA 4:5367 C: ,A L 0 0 a 1 9 0 8 1 6 c
<br /> ro N €R r <F
<br /> i �. - _
<br /> V� 11 US DOT Description(including Proper Shipping Name,Hazard Class,and Ip Numbed 12 Containers 13 Total 14 Unit •� r
<br /> Z r
<br /> No Te Quantity_ Wt/Vol u
<br /> a ; vv�Ya}fl rgf�B�
<br /> 5jnrem,
<br /> (OILY WATER ) i3 (? 4 T C w ° ter, �'T
<br />'3 kEflctdt �_ ,'
<br /> E to E
<br /> 00
<br />' N
<br /> 6 T c r5tnfg �`
<br /> (D O
<br /> ti
<br /> J rfianal ascii r Apr } a �a ^4�r,� � t �y ~
<br /> A'
<br /> "fA"ac
<br /> s1.. zqt �h,�a�' r��.d'�eR��'jp n� x r s z3�°''i7s�-'Z``_'� �a.M..a�.+C �tf�'�!:�t,��',rrr �. �.'r Ss,i 4 Y �''���mk� � r r "�'-,x.•yS� ��!�'r+�' `fir f
<br /> N ze "f-r s;Y� 'c , :a� w,r w �59. ��4 y 'r� �
<br /> ,n++f d<a�iS" a i cy
<br /> � �',�-{� Hn r'} °" i y '• 't r a r a ^S' 'r 'F"`,c�. ¢° "ur
<br /> s� �' .� fir` .E' i
<br /> rr '+ ;;,. M>. v«wr tt "�,r_Y r 4�ri'"ar r'�.�f k xkf r tyw�r.�.r`+"fir U A. , '� ie�j .i A'k <? �r�� Y< � kms„ 9 A
<br /> �'"'� 3 yrs�1.�Y e"'� a' �7F�"�1�.1 �W i��, rr� 1'� „w 3� r � x� era �� '`IF,Q y�,T s '!gi A n<'vr �'y @, '' ,e, #'�' 7x a '`".",3''- r as ri .ern w 4 Y r at S art *,,,�a , � 6,
<br /> W4 tr r°''S" ,:�.:�"ti y rw" r#f ,fit c. j a,-t.s iX.r _a..x .iii }iM"i,`,w'1'4�`, +Yt4t� ''a ` <"7 f"' i
<br /> Q 15 Special Handling lnstruchom and Additional Information '�7 E"w
<br /> Q GLOVE'S
<br /> EMERGENCY PHONE 209 587-8657
<br /> tL
<br /> Q16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed
<br /> < marked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regularons
<br /> If 1 am a large quontiy 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
<br /> N practicable and that I have selected Ike practicable method of treatment,storage,or disposal currently available 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 mode a good faith effort to minimize my waste generation and select the best waste management method that is
<br /> O available to me and that I can afford
<br />' Pr�fed/,Typed Na )�� i r � Signature ry � Months .,.Qay Year
<br /> Z
<br /> 5 T 17 TrcL"Porter 1 Acknowledgement of Receipt of Materials
<br /> NPn /Ty rl IJme + Signature r f Month ay ear
<br /> LU P
<br /> 0 0 I S Tions inm
<br /> rter 2 Acknowled eeof Re i t of Materials
<br /> TPrinted/Typed NameSignature Month Day Year
<br /> LU E
<br />'� R
<br /> U F 19 Discrepancy Indication Space
<br /> Z A
<br /> C
<br />' I
<br /> L
<br /> I .20 FacJi Owner or Operator Certification of receipt of hazardous mafenals covered by This manifest axce t as noted in Item 19
<br /> ���Printed/Typed Name Signature Month Day Year
<br />' DO NOT WRITE BELOW THIS LINE
<br />' DTSC 8022A(1/99) Yellow GENERATOR RETAINS
<br /> EPA 8700-22
<br />
|