Laserfiche WebLink
State of California—Environmental Protection Agency ,— <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) I}- " See Instructions on backAdiime 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(I 2-pitch tee. Sacramento,California <br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> 4 `F. -'1.'R. is not required by Federal law. <br /> 17 <br /> WASTE MANIFEST ' ` f "'7 { <br /> 3. Generator's Name and Mailing Address¢ ' A. State Manifest Document Number tt <br /> r �.� 0 "" i ate'- 4 <br /> O ` Cr. j `e. ,� . B. State Generator's ID <br /> LO <br /> LO 4. Generator's Phone C ) d�fdf =f [fie t k`t^.=.ti' a 1 'All r <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> to <br /> O 11MN16ak'es� .�. 8 .x .. 1312116,12 D. Transporter's Phone 51.0/795-44W <br /> 7. Tr rt 8. US EPA ID Number E. State Transporter's ID Reserved. <br /> Q arm ssf _ ig5.. {r 1t er9 " $ F. Tronsporter's Phone "tea ' <br /> f <br /> t> 9. Designated Facility <br /> gsgp <br /> Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 1+ . <br /> � 2095Lea IARYS DR-RFE RAnT H Facility's Phone <br /> O af w a, g iN iV i D 1.9 13 0 8 19 5 13 zi 18 TIEr-5 -2760 <br /> J <br /> Q 11. US DOT Description including Pro er Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> V e No. Type Quantity Wt/Vol I. Waste Number <br /> Z ° f_•' i r e ,`r` f./F /r. w - State <br /> o 'N b. <br /> State <br /> co <br /> co E <br /> 4� R EPA/Other <br /> C. <br /> A <br /> o T <br /> State <br /> C> <br /> O <br /> R EPA/Other <br /> LU d' <br /> State <br /> Z <br /> V EPA/Other <br /> w <br /> N J. Additional Descriptions for aterial Listed Above K. Handling Codes For Wastes Listed Above <br /> Z /r <br /> O a� / 4 e a b. <br /> LU <br /> a' C. d. <br /> Q Il,C <br /> 0 15. Special Handling Instructions and Additional Information's z-ayG- �e�t- <br /> ;t w <br /> ~ Il a- / d <br /> LU (wo 3121-1-0130 <br /> WF PyaY E I ` � IMI R SI 1le"A_ <br /> 16. 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 /> U marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and not, <br /> government regulations. <br /> If I am a large quantity generator,I certify that I have o pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> Npracticable and that I have selected the practicable method a 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 made a good faith effort to mini ize my waste generation and select the best waste management method that is <br /> °-' available to me and that I can afford. <br /> O <br /> r Prigted/Typed Name Signature. a Month Day Year <br /> t i <br /> Z 1 � wv <br /> .,My.,.-gip ...'•-,-_�.e...__.._.-__- , <br /> w T 17. Transporter 1 knowled ement of Receipt of Materials 1 <br /> R <br /> w A Printed/Typed ` Signatu "t •'f, ,/°, onth Day Year <br /> p <br /> W "s � " r �. �° <br /> P <br /> LL- 0 18 <br /> .' a orter 2 Acknowled ement of Recei t of Materials <br /> 0 T PrintekTyped Name Signature,� ,rf f nh Day Year <br /> LU E <br /> It -2 <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> L <br /> 20.facilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> i <br /> i <br /> A ° <br /> e <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> E <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />