Laserfiche WebLink
34olo c'Gslilorma--Neailh and Welfare Agency Dopartment of linalth S eh <br /> Form Approved OM13 No 3050--00,19(Expires 9 30 91) Toxic Substances Sonlrcl or 101 <br /> Please pant or type (Form designed for use on Oil e 'pifch typewrifer) Sacramento Cal 1 me <br /> UNIFORM HAZARDOUS enerator a US EPA ID No Document sNo t 2 Page t Inlormation in the shaded areae <br /> WASTE MANIFEST <br /> of s rot required by Fedora law_ <br /> 3 rGenerelor s dame and1Mailing IAddre(� r A State <br /> —M_anifest Document Number <br /> lJf1/ '• G/�& j <br /> 4, Y_ <br /> f C S State Gdne alar s ID <br /> 4 C,enerator a Phone r ) r,.r � f � 1 <br /> �I 5-transporter I Company Name E US EPA ID urdbe G tato T r <br /> .1 <br /> D Transporter a Pnone , ^_sti ! <br /> N <br /> to I j� �ctl+ter y`IJo a I? S PA ID Number E Stale Transporter s ID T- <br /> �'i F Transpo•ter a Phone <br /> n <br /> m <br /> 9 Desipna,ed Facility Name and Site Aodress 10 US CPA rD Number G Slat*Facility a ID <br /> 1IH FaLtyfy a hone ---- <br /> < 1 "r S:�sTrf n I c't �f7A°J, 'JFST SACRA'*lI , L� 3 �t l <br /> -i <br /> M I _�_�__�� 12 otat 1A <br /> Containers 19 1 --- <br /> O II 41 US OOT Do-rription rinctuding Pieper Shipp ng Name Hazard Class and ID Number) Quentily Uri Wattle No <br /> ¢I - — - No <br /> e Type IW4/Vol <br /> Z tfV'G,� � �r✓e� Cv�''r bc�X16� �r 1G�/r� t slate <br /> G I EPAf <br /> N < < —1— I 1.1a <br /> E h ' ! State <br /> H R <br /> C, T I <br /> EPA!Other <br /> I R r- —— — State — <br /> ¢I f EPA/Other <br /> I ,� l <br /> Ir d — I I sla <br /> W f i EPA/Other <br /> Q t I I <br /> - - -- l —L <br /> W <br /> J lddihonal Doarriphons for Materials Listed Above Y dandling Codes for Wastes Grated Above <br /> 7_ <br /> C d <br /> a �v � <br /> i 5 Speua Handle a Irlstrschors and Additional Information <br /> _j1 I '{ Gr <br /> T97�W'eA Tnwlr�iTi V 4 Cf.tJI[�L1sJsJ <br /> UI -�-�-- <br /> i GENERATOR S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described abovr,by proper shipping nama <br /> and are ciaaaified packed marked and labeled and are in all respects in proper condition for transport by highway eccording to applicable,nlemaitor,al and <br /> d I national govrrromeat regulations <br /> �I <br /> H 1 am a large quantity, .rl <br /> generator I certify that I have a program in plata io reduce the volume end toxicity of waste generNd n r.l <br /> she degree I have doleiotibJ <br /> Cr I to be economically practicable and that I leve selected the practicable method or treatment storage ar disposal currently availab'o to-he which minimizes the <br /> } present and futum Threat to human health and the environment OR If I am a small quantity generator I have made a pond faith effort to nun mire my waste <br /> [] generation and select the beat waste mensosment method that is available to me and that i Can afford <br /> PnntadrTyped Name / ,/ fi Signature -- hfonfft Day Year <br /> Uj <br /> syi 7 17 _ ledp.menl at Receipt of Materials ' __ _ <br /> R <br /> A Pnnted/Tvpod Name — Signature h4onth stay Year <br /> N f <br /> 0 p <br /> O 13 ran& ortor ckn e 0 ant of Receipt of Materials <br /> R Printed/Typed Name Signature Sronth pay Yaar <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> L' <br /> 4 <br /> L ' <br /> 1 20 Facd ty Owner or Operator Certification of receipt of hazardous mateuala cover. by thlis m st e)cept as no.d in lleaf 19 <br /> yPrmledrTyped Name SignI ur /�/ r -- t yJ 7s% ar <br /> I I�_)AL � <br /> DHS 0022 A(I 188) <br /> EPA B700-22 Do Not Write Below This me <br /> ,Rev 9 88, Pre%taus editions are obsolete <br /> Yellow TSDF SENDS THIS COPY TO GFNEPATOR WITHIN 30 DA) <br />