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TEXAS NATURAL RESOURCE • ;lP'!E OFD <br />CONSERVATION COMMISSION • ~ ~ ~5 ~~~~;~ <br />P.O. Box 13087 - _ ,.. ; - , ~r ~ ~` <br />Austin, Texas 78711-3087 <br />Please porn or type (Form tlasignetl for use on elite (12-pitch)lypewnler.) <br />Form approvetl OMB No 20500039 <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest 2. Page 1 Inlormatlon in the shaded areas <br /> WASTE MANIFEST ~ ~ ~ ~ ~ °~ NO.' of 1 is not required by Federal law. <br /> 3 Generator's Name and Mailing Address ITEC Mineral/Gold Hill Mill A. State Manifest Doeument Number <br /> 9145 Sunshine Canyon Drive <br /> <br /> Boulder, Colorado 80302 B. State Generator's ID <br /> a Generalor'sPhone( 303 ) 478-1898 99908 <br /> 5 Transporter 1 Company Name ~ 6. US EPA ID Number C. State Transporters ID 027 <br /> /~y ~~t ~r, , c A~ $ ~ ~ D. Transporter's Phone 30 13 y - y 7/D <br /> 7. Transporter 2 Company Name / 8. US EPA ID Number E. State Transporters ID gG <br /> ~ ,,,3 ey~~ij7)o ti~ GL~ ~, <br /> G. State Facility's ID <br /> Eltex Chemical 30271 <br /> 4050 Homestead Road H. Facility's Phone <br /> Houston, Texas 77028 T.XD079196338 713.674.2406 <br /> I t~. 11. US DOT Description (including Proper Shipping Name, Hazard Class, ID t2. Containers 7 Sal urnl I~ <br /> HM Number antl Packing Group) No. Type puantity WI/VOl Waste No. <br /> XX aRO, Waste Sodium Sulfide anhy rous DM P OUTS H <br /> . , <br />• 9.2, UN1385, PGII. ~~ DQ'J3 <br />OD <br />E lOOO 1026 27 <br />N <br />E b <br />R <br />A <br />i <br />O <br />R <br />C <br /> d. <br /> J. Additional Descriptions for Matenals Listetl Above K. Handling Codes for Wesles Listed Above <br /> (Ar) CA) M141 <br /> t5. Special Handling Instructions and Additional Information <br /> (A) ERG #135, EMGY #713.674.2406 Eltex, Contact John Black. <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are lolly antl accurately described above by proper shipping name antl are <br /> ciassdied, packagetl, marketl. and labellatl/placarded, and are in all respects m proper condaion for Iranspon by highway accort icable imernalional antl <br /> national government regulations, indutling applicable state regulations. <br /> It I am a large quamny generator, I certify that I nave a program in place to reduce the volume antl toxicity of waste generatetl to the degree I have delermmetl to be <br /> economically practicable antl Thal I have eelectetl the practicable method of treatment, Storage, or disposal Currently available Ip me wh¢h minrm¢es the present and <br /> IWUre threat to human health and the environment; OR, it I am a small quantity generator, I have made a good fadh eaort tp mrmmize my waste generation and sales <br /> the pest waste management method mat is available to me and Thal I can aaord. <br /> PrintetllTyped Name Sig a ~M6nlh ~.DaytlYear <br /> /v1 AX I N~ S~wR-2T '~_ II 25 ?~ <br />T <br />R t7. Transporter 1 Acknowledgement of Receipt of Materials Date <br />,, Print Name Signature Monrh Day Year <br />s / <br />!N /~ / ! ~ <br />P <br />0 <br />78. Transporter 2 Acknowledgement of Receipt o Materials <br />Dale <br />R PrintetllTyped N/ame / <br />~ Signature Month Day Year <br />~ <br />B e/ <br />7.«» ~/le/ ~ <br />~2 O~/ 5~ <br /> 19. Discrepancy Indication Space <br />F a. rcnuved Uoal . F}4d=d Da'3. CYl <br /> <br />A <br />e <br />I <br />~ <br />I 20. Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as notetl in Item 19. <br />r <br />y <br />Date <br /> P i t dlfyped N~ e <br />1 Signatur Mpn(h De year <br />1 <br />l ! <br />r' ( <br />i <br /> ~ ~ l <br />O <br />N <br />! <br />8 <br /> <br />7NRCC-03n (Rev. 07/0 t/97) White -original PmK-TSD Facdiry Yellow-Transporter Green-Generators hrsl copy <br />