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State of California -Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of le 6. Department of Toxic Substances Control <br />Please prinF or type. Form designed For use on elite (12 -pitch) iter. S t C U <br />G <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRIT BELOW IS <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To: P.O. Box 3000, Sacramento, CA 95812 <br />acromen o, a i orma <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />L D 7 c. 57 <br />rafr <br />is not required by Federal law. <br />3. Generator's Name and Mailing Address <br />Is _2- V� <br />A. State Manifest Document Number <br />- 22744657 <br />�G A r m t G S Toc,- T old -144.�S � <br />B State Generator's 1D <br />4. Generator's Phone <br />'26g) <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />V I #P-0� M e � / * �+ <br />D. Transporter's Phone 70_ �2- ^� <br />7. Transporter Company Name 8. US EPA ID NumberE. <br />State Transporter's ID [Reserved.] <br />'• <br />t <br />/2 <br />(p �� � S � � � � S � <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />C2vs6t/0uerToA/ <br />G. State Facility's ID <br />G <br />LI a Iclel O O ' <br />H. Facility's Phone <br />N O IC1,41bl &I'll 91 qj 011 o 1� <br />� 3 -5 C/- q s <br />11. US DO Descri tion (including Proper Skipping Name, Hazard Class, and ID Number <br />p ( g p^ pp g , H ) <br />12. Containers <br />�ftQuanH�ly <br />14. Unit <br />WI/Vol <br />1. Waste Number <br />No. <br />Type <br />a. <br />/� <br />N rL. (•.� A � -2-A /Gp 0 L. -C W -4 5T� <br />State 3 <br />G <br />/� <br />S Dl I C I S ler 1� i F!� Is S C-- /G G # I7r <br />O'EPA/Othgr <br />Io -0 <br />E <br />/ <br />�� <br />N <br />b. <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />State <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Additionaf'Descriptions for Materials Listed Above <br />K. Handling Codes fo ,Wastes Listed Above <br />7` o 3 ` S S �r�o �� l <br />a. b. <br />c <br />d <br />15. Special Handling Instructions and Additional Information <br />��sytB✓ ewr-y P 9Sp0Avse 0 -7 <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, packed, <br />marked, and labeled, and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br />If I am a large quantiy 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 />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />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 waste management method that is <br />available to me and that I can afford. <br />Printerl/Typed Name <br />y([_ <br />Signature <br />Month/ Day Year <br />CO <br />T <br />17. Transporter I Acknowled a ent of Receipt of Materials <br />R <br />11 <br />x <br />Printed Typed Name <br />��S <br />Signature <br />Month Day Year <br />S <br />P <br />lit/ <br />0 <br />18. Transporter 2 Acknowledgement of Re ei t of Materials <br />R <br />T <br />Pri ed/Typed Name Signature Month Day Year <br />E <br />R <br />F <br />iscrepanc ndication Space <br />A <br />C <br />I <br />L <br />�— <br />1 <br />20. Facility Owner or O erat C rtificatio of receipt of hazardous materials o e y mcsnife,--1-e-ftW as noted in Item 19. <br />T <br />Y <br />Printed/Typed Nameignafure�-� <br />_ <br />onth ?Day Year <br />J <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRIT BELOW IS <br />White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />To: P.O. Box 3000, Sacramento, CA 95812 <br />