Laserfiche WebLink
"State of California—Environmental Protection Agency ORM # 169072 <br /> Form Approved OMB No.2050-0039(Expires 9.30-99) See Instructions 0n back Ofe,6. Department of Toxic Substances Control <br /> lease print or type. Form designed for use on elite(12-pitch)Oiter. 6 Sacramento,California <br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal low. <br /> WASTE MANIFESTCAD 10 17 14 16 14 12 19 10 11 9 1 4 1 1 1 11 of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> i20 4 <br /> e <br /> 1029 <br /> 0DI a°� {� ° O •�° <br /> B. State Generator's ID <br /> 4. Generator's Phone.(209 ) 333-3500 ' is � <br /> �N 5. Transporter 1 Company Name 6. US..EPA ID Number C. State Tronsporter's ID[Reserved.] <br /> ao2S & WIM."; IW. D. Trans otter's Phone <br /> �O A 3 ® 9 5 6 p 460-436-87'00 <br /> 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Transpolter's ID[Reserved.] <br /> VA tTY� �l g a F. Transporter's Phone <br /> � p323,-265-812a <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Z PO SL"tI`E;r�'1 M °Oil H. Facility's Phone <br /> "EDONIl Y5 66736= F, I S I L I S, I R, 10 1613 1312- 15 3 316-379-4451 <br /> V12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. I Type Quantity Wt/Vol 1. Waste Number <br /> Z a.R p P RELATED MATERIAL AL State <br /> _ 3, 1263, PG IIs (RQ=100)r (EPA P003 D001), <br /> G (ERG 1.27} J CJ EPA/Other. <br /> oN b. State <br /> co E <br /> v R EPA/Other; <br /> 4 A <br /> State <br /> o T <br /> 0 Q <br /> R EPA/Other <br /> LU d. State <br /> Z <br /> U EPA/Other' <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 111A. GRIO133—VAOZ b. <br /> ADDITIOWAL RIPA C43 11&. _ `: ]p1 <br /> C. <br /> d: <br /> 0 15. Special Handling Instructions and Additional Information VaAR APPROPRIATE PROTECTIVE GEAR WHM BANDLING <br /> aPMRGM-.T 0JNTACT# CHEWRECt 1-800-424-9300. CALLM. MUST IDENTIFY VANS WATERS & <br /> Z ROGMSASSHIPPER: <br /> = 117 . 10733-VA02 <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 /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantify 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 /> CL 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 health <br /> N 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 is <br /> available to me and that I can afford. <br /> O <br /> } Printeded Name Signatulre Month Day Year <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R _ d <br /> UW A Printed/yped Name Signature ; Month Day Year <br /> W P ;C,✓t''�. •'.^ .. f $r l i.._.A..-.... i -...., �N +..,..4_-K: r' 1 ..�-� !- (_. <br /> LL 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> G T Printed/Typed Name Signature Month Day Year <br /> w E <br /> V) R <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> i <br /> L <br /> f 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> j Printed/Typed Nome Signature Month Day Year <br /> i <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />