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State of Colitornia—environmental Protection ,vgOn'cy <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back Of Page 6. Department of Toxic Substances Control <br />Please phot or type. Form designed for use on elite (12 -pitch) typewriter. Sacramento, California <br />O <br />in <br />h <br />CN <br />h <br />O <br />0 <br />aD <br />C <br />�V <br />'Z <br />0 <br />ti <br />rr�Q <br />L_ <br />H <br />3 <br />CV <br />O <br />ao <br />ao <br />-t <br />CV <br />V <br />0 <br />0 <br />ao <br />rY <br />w <br />t— <br />Z <br />w <br />V <br />LU <br />N <br />Z <br />0 <br />a <br />rn <br />LU <br />J <br />Q <br />Z <br />0 <br />t•= <br />Q <br />Z <br />LU <br />S <br />Q <br />V <br />J <br />d <br />rn <br />0 <br />} <br />V <br />Z <br />LU <br />0 <br />LU <br />LU <br />LU <br />LU <br />tL <br />0 <br />LU <br />rn <br />Q <br />V <br />fU <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow; GENERATOR RETAINS <br />EPA 8700-22 <br />UNIFORM HAZARDOUS <br />I trator's US EPA ID No. Manifest Document No <br />2. Page 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />of <br />3. Generator's Name and Moiling Address <br />A. State Manifest Document Number <br />24780191 <br />B. State Generator's ID <br />A. Generator's Phone ( ) ; . _ <br />5. Transporter 1 Company Nome 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />D. Transporter's Phone <br />_ <br />1. <br />1. <br />7. Transporter 2 Company Nome B. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9, Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />H. Facility's Phone <br />c,�c <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />, __ <br />State <br />G <br />EPA/Other <br />1.c <br />Nb. <br />State <br />E <br />EPA/Other <br />R <br />A <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 />a. <br />b. <br />�c- <br />d. <br />15. Special Handling Instructions and Additional Information <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 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 />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 />Printed/ yped Name <br />SinotuJe <br />Month Day Year <br />T <br />17✓ Transporter 1 Acknowled ement of Receipt of Materials <br />R <br />I <br />Printed/Typed Nome ,r <br />Si nature Sy' - .. ; _. <br />9 „- ,.- ,, <br />Month Day Year <br />r <br />S <br />P <br />0 <br />_ <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />1 <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />I <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow; GENERATOR RETAINS <br />EPA 8700-22 <br />