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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 p, 6 <br />Please print or type. Form designed for use on elite (12 -pitch) tyt rr. <br />O <br />LO <br />Ln <br />fV <br />Ln <br />aD <br />O <br />O <br />tb <br />R <br />yZ <br />)cX <br />C) <br />`Q <br />,U <br />Z <br />2 <br />3 <br />c� <br />C <br />ac <br />cc <br />c <br />C <br />cc <br />a <br />LL <br />r <br />Z <br />LL <br />LL <br />V.Z <br />C <br />o. <br />V <br />LL <br />C <br />Z <br />C <br />F <br />4 <br />2 <br />LL <br />1 <br />F <br />L <br />Department of Toxic Substances Control <br />Sacramento, California <br />DO NOT WRITE BELOW TH15 LIM. <br />DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />1. Generator's US EPA ID No. <br />Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />Iof <br />3. Generator's Name and Mailing Address - <br />A. State Manifest Document Number ^ h <br />j r,` ,_•r.�,•" - <br />B. State Generator's ID <br />4: -Genera of"s, PhOne,( . <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. State Tronsporter's ID Reserved.] <br />D. Transporter's Phone <br />j7. Transporter 2 CompdnyrNam`e• 8: US EPA ID Number <br />_ <br />E. State Transporter's ID (Reserved -j - <br />F. Transporter', 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 />17•rh ., <br />^ <br />-14. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />1"2. Containers <br />No. <br />Type <br />13. Total) <br />Quantity <br />Unit <br />Wt/Vol <br />I. Waste Number <br />o. <br />State <br />EPA/Other - <br />Pj t : `_'.1» 1 <br />G <br />. <br />E <br />b. <br />State <br />N <br />EPA/Other <br />E <br />R <br />A <br />State <br />T <br />c <br />EPA/Other <br />O <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 />in For transport by highway according to applicable international and national government regulations. <br />marked, and labeled, and are in all respects proper condition <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 economical)y <br />the method of treatment, storage, or disposal currently available to me which minimizes the present and Future threat to human health <br />practicable and that I have selected rracticable <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/Taped Name Signature <br />Month Day Year`s <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials �- <br />i <br />Printed/Typed Name Signature <br />_ Month Day Year _ <br />- ' <br />P18. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />Month Day Year <br />R <br />Printed/Typed Name <br />Signature <br />t E <br />1 R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />1 <br />T <br />Printed/Typed Name Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW TH15 LIM. <br />DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />