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fitale Of Caulorms--Heeim and Welle•e Agency Derar f+011111h Syr ces <br /> Form Approved OMB No 2050--0039(Expires 9 30 91) TO [ St.Dstances L dntrpl D+o�9 ion <br /> Please or nror type (Form.tes+gned for use on ehle( 2 p+l[n lypewr+fer) { Sa lamen+q Ca„19rnie <br /> UNIFORM HAZARDOUS y4 ®ttt s.US.�PAJAel4°� 7(�� Document No 2 Pspa 1 talormahon the shaded Weaa <br /> WASTE MANIFEST V V SCJ oa i is no1 regwrad by Faaa-1 is. <br /> 3 Garygra�p s N9.me�r Malllnu AdGress n �74��i��d�^�yd/n �y A State anileat Oocumeent Number <br /> of1T/iV -y� � � (l `V �Jlf�r7V�Y 0 09 5 .. , <br /> l!! 4 B t at <br /> 91 9eneraror s¢hone <br /> U71 5 Transporter 1 Company Name —� J d .)S E&FID Number C Stale Transporter to .) <br /> or <br /> D Transporter• <br /> CD 7 Transporter 2 Company Name 8 US GPA 10 Number E 11tate Transporter a ID <br /> O <br /> F Transporter a Phone <br /> Ji 9as+ Hated Facility Name nq,Srle aar��� 10 US EPA ID Nu-bar 0 Slats Facility s iD <br /> ?000 -Ou '9� —G :Jc. H Facility aPhone <br /> cc JOLA r—,Qk—iC2 6V <br /> O I /� 12 Conta,nors 13 Total } 1a <br /> LL t <br /> f 1 US 0OT Description(including Propez-Aivpmg Name Hazard Class and in Number) Quantityi Unit Waste No <br /> No Type WI Vol <br /> - T G r�v'I State <br /> © X G P1 OIL /i�iN.4 <br /> JS. V Kf�`L VEC�� 2� <br /> C ~ N ..,J'ji G s..,. _ w Ll6 L( 16 Nr � IlJlj If ! �4EPAi0ther <br /> E b <br /> C R } State <br /> li <br /> S <br /> A <br /> T <br /> o O I EPA+Othar <br /> v R C <br /> S State <br /> m <br /> EPA/Other <br /> d State <br /> Z <br /> U <br /> EPA/Other <br /> LU <br /> rnJ Additional Descriptions for Metenals Listed Above K Handling Cotler for Wastes listed h:we <br /> dI � <br /> o � <br /> C t5 Spaeisl Handling Instructions and Additional(nlormahon <br /> 11744—f <br /> w�yr _aR1),flY�, 1 <br /> rVi/ 9e 1��)y7 <br /> 17 <br /> VJ F,412 6- L'� / f>- <br /> u <br /> 'g V;rZ�At/ .c civ is""----- <br /> 1 <br /> GENERATOR CERTIFICATION I hereby declare trial the contents of this consignment are fully and accurately described above by proper�Aippmg name <br /> a and are cfasa+hed pecked marked and labeled and are in all respects in proper condition fcr transpoil by highway&cc*fr�lnq 1 apppph�� le apt rnelranal r�,r�1 jj <br /> N national government regulations f / <br /> If f am a large quantity gone rRtor t cartdy that I have a progrAm on place In r@duce the volume and lovi0+ly of waste gene atatl o the degree I nave determined <br /> p 10 ba economically practicable and that I have seleclatl the WaetlC4010 method of treatment storage or disposal currently available to me w4+ch mmimixos the <br /> y t present and future throat to human health and the environment OR if I em a small quantity generator I have made a good farlh ellon to minimize my waste <br /> C.1 generation and as act the beat wasla management method that a available to me and'hat I can afford <br /> pngWiTypeo`lame SignatureMonth Del Year <br /> cc e--171 <br /> W, R 7 Transporter t Ackriowledglemellat Receipt of Materials <br /> NPrinted/ Name Signature Monrrl Day Year <br /> 5 [:'Illn7ransporlerv <br /> U.1 I p 2 Acanowledg•'nont of Receipt of Materials <br /> Ui R PnntadfTyped P sing Signelure Month Day Year <br /> ( E <br /> x` R <br /> — E I i <br /> 19 Dise,apancy+ndicarion Space <br /> i <br /> F <br /> ` A <br /> C I <br /> I <br /> L <br /> I 20 rac+tity Owner or Operator Cerldiaapon of receipt of hazardous materials covered by this r,endesl except as roted in Item 19 <br /> T — ' <br /> y Pnnletlr Typed Na me 5+gnature M�nfn Day Year <br /> DHS 1022 A(I tial .. ._....�.-.. .,__ ! ` , <br /> Jo Not Write Below This t ne <br /> EPA 8700--22 <br /> (Rnv 9 88)Previous editions are obsolete <br />