Laserfiche WebLink
i Statedlifor —Enviropmentol Protection Agency <br /> ForrFi roved O B No.4050-00391{Expires 4-30-99) "y, See.lnstructions on back o ge 6. ^� (! Department of Toxic Substances Control <br /> Pleas nf-or For.n designed for use on elite 12- itch ter.?` " (i (t/ <br /> w :. !YP � 8,.. .. ( P t - Sacramento,California <br /> U�IFO {1AZAR®OUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> 1�7 ' WASTE MANIFEST "is not required by Federal law. <br /> CAl 4 All- g 0 1 X 6 3 5 2 of <br /> I Generator's[Name <br /> r and Mailing Address <br /> �� / <br /> 1029 :3 SACRANUM ST <br /> LOD11 C1 95240 § <br /> A. Generator's Phone( 26,D) <br /> D) 3.,•3500 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number <br /> a V a ROOM WC <br /> 0I CIA q q 11 q M 21617 <br /> 7. Transporter 2 Company Name 8. US EPAI Number <br /> VM wok"ra 1; R0108" w�-as <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number ` <br /> PO am ill <br /> ,)0 � 3 6 <br /> IQ 12. Container 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> D'V No. T pe Quantity Wt/Vol <br /> 3 a.RQI <br /> 263, PG 11* (V-100), (RPA D001 D035), <br /> W3 G { 127} e 01/ 161010 <br /> t" <br /> E <br /> na0o N 3,b 263,r PCS 11, (RQ-100), {EPA 3 D001), <br /> co E 1.x7} <br /> -4 RDIM 014,1611flO, <br /> 0o T , c. <br /> co O <br /> R <br /> w d. <br /> Z <br /> LU <br /> V <br /> w <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information WM AMOMMIDLING. <br /> M"Mct.; = C804TMi 1-800-424-9300. CUAM MUST IMM17T VAN WATUS a <br /> Z ROGMS AS 0214 <br /> W Im rA38633r lib, M7tA'&10733'"'I;s02 <br /> 16. GENERATORI 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 /> Vmarked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> 1 <br /> J+ If I am a large quantigenerator,.)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 economical) <br /> N <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heal ' <br /> and the environment;OR,if I am a small quantity generator,I have made a good Faith effort to minimize my waste generation and select the best waste management method that' <br /> available to me and that I can afford. <br /> O <br /> Pri yped NameSignature Month-•' Day Yet ' <br /> �r ... <br /> n, <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w A Printed/•y ed Name Signature Month Day Year . <br /> R .. i. <br /> w <br /> LU <br /> U- 0 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name $ignatur r Mont Day xear� <br /> Q e I RAAJe /G $ Vt t -, (if k7 <br /> V 1'9. Discrepancy Indication Space <br /> Z F <br /> _ A <br /> C <br /> L <br /> f 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by t s rh6nifesttexcept d's noteA in Item 19. <br /> T Prin d/T ed Name Signature i Month Day Year -: <br /> DO NOT V41TE BELOW THIS LINE. <br /> DTSC 8022A(4/97) <br /> EPA 8700-22 White: TSDF RETAINS <br />