Laserfiche WebLink
AS NATURAL RESOURCE PCE OF <br />JNSERVATION COMMISSIONTia <br />O. Box 13087 <br />41 jstin, Texas 78711-3087 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form approved. OMB No. 2050-0039. <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest <br />2. Page 1 <br />1 Information in the shaded areas <br />WASTE MANIFEST • • . . Document <br />of <br />I is not required by Federal law. <br />3. Generator's Name and Malling Address C O S TC O <br />RD <br />A. State an"Ifest Document Nuppmb++e��r ++-. <br />S09283 <br />32.50 W GRANTLINE <br />J <br />B. State Generator's ID <br />TRACY CA 5 3 7 7 <br />4. Generator's Phone ( 2 0 9 8 3 0- 5 3 4 3 <br />D0606 "` <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transpofters.lD <br />D. Transporters Phone:: _ ; <br />f: _ <br />,.` r <br />7. Transporter 2 Company Name8. US EPA ID Number <br />E. Stale TranSpdrWs ID <br />F. Transporters ftone'.:' <br />9. Designated Facility Name and Site Address C)00o 16 10. US EPA ID Number <br />G. StatefecilitylD <br />SAFETY-KLEE14 SYSTEMS, Itr'(`. <br />65124 <br />H.Facil'ItysPhone <br />1722 COOPER CREEK ROAD <br />DENTON, TX 762.08 <br />:t <br />9404 M <br />11A. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, ID <br />P (• 9 P PP� 9 <br />12. Containers <br />13. <br />Total <br />14. <br />Unit <br />HM <br />Number and Packing Group) .. <br />No. Type <br />Quantity <br />wtrvol <br />a. <br />WASTE S(JL-1DS CONTAIVINCv fi:AM ASLE- <br />c <br />LIQUID"; N. U: 5...t.rAS�i:iE," 3£1�Z£3�I£ -4 :-4 <br />DM <br />P <br />_ <br />E <br />.. ..._ .. _ _ <br />N-- <br />E <br />b. <br />_. <br />R <br />A <br />WASTE SOLIDS CONTA111ING FLAMMABLE <br />L lQTJI D. N. 0. S. ( GASOLINE, BENZENE ) 4. 1 <br />' <br />i;C1 <br />;) / F. , <br />P <br />UtI' <br />_ <br />11 <br />WASTE FLAMMABLE LIQUIDS, N. 0. S. <br />ERG#1 28) <br />:L; :� <br />DM <br />C`' <br />P <br />Q U'. <br />(GASOLINE) 3 UN199 3 PG II ( <br />::'<� <br />;.. <br />d. <br />Y., dditiortat Descriptions foupptIaaterials •Lis6eij �ttoits K. Handling Colles for Wastes <br />r i�c8 flOUi'AM <br />Ts9th X40 ' <br />15. Special Handling Instructions and Additional Information <br />tdFST R/T#103986875 0002-8E 17-22 <br />EMERGE14CY RESP 800-468-1760(24 HR.), IF UNDELIVERABLE RETIJR14 TO GENERATOR. <br />SK CORP AUTH'D TO USE SUBSEQUENT CARRIERS: 81300,40355,41015,405,2,84815 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and are <br />classified, packed, marked, and labelled/placarded, and are in all respects in proper condition for transport by highway according to applicable intemational and national <br />government regulations, including applicable state regulations. <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 <br />future 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 <br />the best waste management method that is available to me and that I can afford. <br />Signature Month Day -Year <br />Phnted,Typed Name <br />J All <br />Date <br />T 17. Transporter 1 Acknowedgdmeiit o Receipt bT-M mals <br />R <br />Printed/Typed NameSignature <br />NMonth Day Year <br />/ f <br />s , <br />0 18. Transporter 2 Acknowledgement of Receipt of Materials Date <br />RMonth Day Year <br />Printed/Typed Nante Signature <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />I <br />20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />Date <br />T <br />