Laserfiche WebLink
$ f7 <br />State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-94) See Ins".ipns on back 6. ( Department of Toxic Substances Control <br />'Please print or type. Form designed for use on elite (12pitc ricer. `''"' Sacramento, California <br />x <br />1. Generator's 115 EPA ID'Wo. Manifest Document No. <br />UNIFORM HAZARDOUS 2. Page 1 Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST110104011441i '9 Of <br />3. Gene or's I�pgye an ailing Ad {rsyo oft. S <br />to <br />�+� I+t <br />n <br />N <br />4. Generator's <br />-75 <br />to <br />ORA 1-31- AS <br />0? <br />O <br />5. Transporter 1 Company Name 6. US EPA ID Number C. State"'lransparter s ID <br />O <br />.e. ap <br />. . D. Transporter'; Phone <br />3�7 <br />. ,..s -, ,,S 40i� 5 _ <br />7. Transporter 2`Company :Name 8. US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br />�''1E✓1 <br />3 i�:yG�'1.1. b t ')g`%�".t�,fw�$'9>&..# o {{ <br />O <br />1515 SOM RIVER ROA -7) WEST SAaW0Mj CA 95691 H Facility s Phare <br />CAD04400355 f11,� <br />U12. <br />' Z <br />Containers 13. Total 14. Unit <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) No. Type QuanTi Wt Vol to <br />tY / YTpctmlaer ., .. <br />a' % Alf) <br />s ft <br />*4 <br />r <br />G <br />L yyit <br />�pN A O l'o 'd <br />010 t <br />- <br />Z <br />E <br />it dk tt <br />0 <br />00 <br />N <br />b.� <br />0° <br />E <br />cN <br />R <br />A <br />o <br />T <br />C <br />0o <br />O <br />R <br />EPA,tQfher `i <br />LU <br />Zd.� <br />,.. <br />LU <br />U <br />LU <br />a Z <br />} dtlwtLonal D cTtptions fos Materials listed Above K Bandl s <br />CLO <br />a 6 <br />LU <br />c sate <br />». s <br />Z15. <br />Special Handling Instructions <br />ons an»d.,Additional <br />onal InformationO fo1 <br />< <br />MTS M 40 Kiri OSM/SMA 2' AMD <br />Z <br />AND USE NIOSPI APPRO PPE, <br />LU <br />. <br />annert 916-371-5747 <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, <br />Q <br />packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />U <br />If I am a large quantity 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 <br />economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and f_ulure <br />n <br />threat to human health 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 <br />waste management method that is available to me and that I can afford. <br />W <br />O <br />Printed/Typed Name v Signature p % , <Vl Day ,',Year " <br />-. Z <br />k <br />17. Transporter 1 Acknowledgement of Receipt of Materials- <br />e <br />L1J <br />" <br />n <br />Printed/Typed Name <br />Signature _ :. <br />"' <br />.Month Day Year <br />LU <br />s <br />>YvK1�. <br />9 iIg <br />::E0 <br />P <br />18. Transporter 2 Acknowledgement of Recei p t!of Materials01 - <br />LU <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />LL <br />O <br />E <br />R <br />., <br />~ <br />w <br />19. Discrepancy Indication Space <br />' <br />N <br />y , <br />U <br />C <br />Z <br />1 <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifost except a, noted in Item 19. <br />„T <br />y/- <br />Printed/Typed ince/Type Name _ <br />ignat ur <br />Month Day Year <br />rell <br />1' <br />O <br />l <br />DO NOT WRITE BELOW THIS LINE. <br />w.F'' `°yellow: TSDF SENDS TOPY TO GENERATOR WITHIN 30 DAYS <br />s-' DTSC 8022A (9/93) 'a - c (Generators w mit hazardous waste for transport out state <br />f <br />EPA 8700-22 produce comp) copy of this copy and send to DTSC within 30 days.). <br />s,�kk <br />a...:'�''r1x'tw', - <br />