COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

State of California—Environmental Protection Agency Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back f ige 6. Department of Toxic Substances Contra Please print or type. Form designed for use on elite(i2-pitch, writer. Sacramento,California UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Poge 1 Information in the shaded areas WASTE MANIFEST ~` [ Y is not required by Federal law. of 3. Generator's Name and Mailing Address A. State Manifest Document Number r,1, J kof CD y'.' B. State Generator's ID n 4. Generator's Phone ii• J":? s:i(�(j;' 7 =,; L e r CA 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] cp pD. Transporter's Phone O - '1.`ti +-i ib':u'i:i.i217ie='.: : �3t.',-4z4�t c .s`if. P-,.. _ 3 7 - 'rt 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] Y)J I I I I I I I I I I I F. Transporter',Phone U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID Z e. .!r�': �`T`"` s �' H. Facility's Phone .. . ,. I..:.•t s.xr i11 1..1.rr$1`.;F7i:t�1.]�`%;(:`^: Q :S F \ � ��J_�f„' t iC-.} )pwi• s 1 Q 12. Containers 13. Total 14. Unit U 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number a G-Zolk lam'korRti2J-U'Fe State f_ FV 3 G it 1� .VT EPA/Other E h 'IY'It O N State o E -4 R EPA/Other v A O T c. State aoo O R EPA/Other F d. State Z Lu U EPA/Other J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above 2000 NcRt 1A„TKAe8"lSm EMIRtw`s3D-T lr R.l=°.?,A"ACA",5E(XIME 140. 126 a. b. cL : ` � , 51U..,;.� . dfn,0.9, ms Q F1:13C Citwim.21 1796 c. d.Z O 15. Special Handling Instructions and Additional Information _ ~ =: r ' ARCO 4+32 t� .5 11_q; . t � a- X1` e : Z (940" :_/53-5 8_26(24 1_18'dmkWr ; 1 �Y)450-1 M 0”.m.-Ph'I m.1 tw tlpr s ) Stockto%, CA 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, Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. v J 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 economical] y practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health n and the environment;OR,if I am a small quantity generator,1 have made a good faith effort to minimize my waste generation and select the best waste management method that is Oavailable to me and that I can afford. Printed/Typed Name Signature f �+ Mandl, Day Yea(_t Z �..a&7';Y`tiJl5ill.-ii1(�jLt' Zt.rT�yL''s.ti'Li� -.,'..% T",✓'� "! '."""'{..-.. r Lu T 17. Transporter 1 Acknowledgement of Recei t of h aterials It w Printed/Typed / Signature,- ' � Month., Day Year _ " f r" Lu P .� •r' •1. ' I .(� s�j4 ,...... .. S f.._ � 0 18. Trans orfe 2 AcknowleA ement•of Receipt of Materials ll.• 0 T Printed/Typed Name / Signature Month Day Year Lu E `f to R _.% (Qj 19. Discrepancy Indication Space Z F A C I L 20. Facili Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. 7 Printed/Typed Nome Signature Month Day Year Y DO NOT WRITE BELOW THIS LINE. DTSC 00-22(1/99) EPA 87700— Yellow: GENERATOR RETAINS