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State of Cali Frrnia—Enviran mental Protection Agency <br />Form Apprdved OMB Ne. 2050-0039 (Expires 9-30-99) See Instructions on back of -ge 6. Department of Toxic Substances Control <br />Plea%print or type. Form designed for use on elite (12 -pitch) iter. Sacramento, California <br />O <br />LO <br />LO <br />N <br />CV <br />LO <br />00 <br />O <br />O <br />CP <br />VJ <br />DQ <br />DU <br />�3 <br />CV <br />O <br />co <br />co <br />V <br />CV <br />O <br />O <br />co <br />LU <br />t— <br />Z <br />U., <br />U <br />w <br />N <br />0 <br />V) <br />w <br />Ce <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRI�AELOW VAINE. �J <br />TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />P.O. Box 3000, Sacramento, CA 95812 <br />White: <br />To: <br />Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />Il. <br />UNIFORM HAZARDOUS <br />is not required by Federal low. <br />WASTE MANIFESTG <br />a 7 <br />( of <br />3. Generator's Name and Mailing Address <br />A, State Manifest Document Number <br />IT01,S-�- L -s <br />A � {� C -- ! ©C. t� 7-o rte,-6Ce4 9 5 X 0 - <br />S'I3, <br />Z <br />2`5202.662 <br />State Generator's ID <br />6 Y <br />A. Generator's Phone ( �/ L <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] - <br />b <br />D. Transporter's Phone <br />7. Transporter 2 Company Name B. US EPA ID Number <br />E. State Transporter's ID [Reserved] - <br />�C011F. <br />Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State F *i 's D. <br />C2oS�, — Ov e TOcti <br />© W e S % 7 f3H. <br />Facility's Phone <br />Gg �L �08'i d d <br />15 eoe3Z�S S <br />1. U5 DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. <br />Containers <br />13. Total <br />Quantify <br />14Unit <br />. <br />Wt/Vol <br />- Waste- -. <br />7. Number <br />No. <br />Type <br />a' Gtll4S %P 4 �• f/ O S O is r /�tNrvs 9 �O �Y CEcLNo% ee �d.. <br />State <br />`7f <br />EPA/ath <br />b 66 <br />�I 50 �`� 1* 1 Z� <br />f L c.Ff2 <br />0 <br />1 <br />A Y� <br />a / <br />P <br />E <br />N <br />b <br />State <br />E <br />EPA/Other <br />R <br />c. <br />State <br />T <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J, Additional Descriptions For Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />15. Special Handling Instructions and Additional Information 2 <br />40 <br />"':577 �"1= 5 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate), described above by proper shipping name and are classified, packed, <br />labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />marked, and <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 economically <br />and that I have selected the practicable method yarn <br />storage, or disposal currently available to me which minimizes the present and future threat to human health <br />practicable <br />and the environment; OR, if 1 am a small quantity generator, 1 have made a good faith effort to minimize my <br />waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Typed <br />D� <br />Signature <br />1 <br />Month Day Year <br />d o ore <br />T <br />17. Trans orter 1 Ackno ledement of Receipt of Materials <br />'R— <br />Printed/Typed Name <br />Signature <br />Signature <br />Day Year <br />R <br />i S <br />P <br />018. <br />Tr s orler 2 Acknowledgement of Receipt of Materials <br />of D Year <br />t iSi <br />Print d/ ped Name <br />9 nature <br />t E <br />R <br />I <br />A <br />1 a n icalj 5 e <br />C <br />1 <br />1 <br />20. FacilityChvner or Operator Certification of receipt of hazardous materials c ed by thisvmanifest except cinotD44ft4amj9. <br />Year <br />j <br />Y <br />Printye�/TTyyped Name / gnatur <br />5���� <br />nth Day <br />Un 4/p <br />(/ t7� • <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRI�AELOW VAINE. �J <br />TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />P.O. Box 3000, Sacramento, CA 95812 <br />White: <br />To: <br />