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State of California—Environmental Protection Agency <br />Form Appro pct OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of page 6. Department of Toxic Substances Control <br />);lease print or type. Form designed for use on elite (12 -pitch) typewriter. Sacramento, California <br />O <br />in <br />in <br />N <br />N <br />in <br />OD <br />a <br />O <br />o0 <br />J <br />Q <br />V <br />Q <br />Z <br />ce <br />O <br />w <br />Q <br />V <br />Z <br />3 <br />C�j <br />0 <br />00 <br />00 <br />v <br />CN <br />V <br />0 <br />O <br />aD <br />LU <br />LU <br />Z <br />LU <br />V <br />V) <br />Z <br />O <br />V) <br />LU <br />J <br />Q <br />Z <br />0 <br />a <br />Z <br />w <br />S <br />J <br />Q <br />V <br />d <br />N <br />cc <br />O <br />r <br />V <br />Z <br />Ww <br />US <br />LU <br />Q <br />N <br />Q <br />l: <br />ii <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A 11/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />UNIFORM HAZARDOUS <br />1, t Jor'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 />f� 4 G' �j �� {'" J (', �� f' <br />of j <br />3. Generator's Name and Mailing Address <br />TO c K' _. r_ t <br />A. State Manifest Document Number ` <br />Q <br />f� _.%221 <br />B. State Generator's ID <br />A. Generator's Phone (2ai) 1 4-14i f <br />5. Transporter 1 Company Nome 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />Jf <br />D. Transporter's Phone <br />7. Transporter 2 Company Name 8. 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 />CS/ ' % <br />i� <br />A <br />H. Facility's Phone <br />3 to !j T %" !j <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />12. Containers <br />No. <br />Type <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />1. Waste Number <br />a. <br />C> AJ Alj ,:�,r 3 x� �, !% s� s <br />State <br />,r <br />EPA/Other <br />E <br />b. <br />State <br />N <br />E <br />EPA/Other <br />R <br />Ac <br />state <br />T <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 />3�Q <br />a. <br />b. <br />c. <br />d. <br />15. Special Handling Instructions and Additional Information _ <br />(� ,�i1' tr=' ; j' _r; �..✓ �.t/ <' � �� �� {� ,_ � ,�./ C R=��'f-ter_:-�: _ "s ;� -` ; ^.: <br />rj <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 />labeled, in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />marked, and and are <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 />have 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 selected practicable <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/ d Name <br />Signature <br />9 t <br />Month Day Year <br />/ i <br />T <br />RSignature <br />17. Transporter 1 Acknowled ement of Receipt of Materials <br />Printed/,Typed t4ome <br />i - <br />Month Dear Year-, <br />A <br />. <br />L-4 Jam. <br />P <br />0 <br />R <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Signature <br />Month Day Year <br />Printed/Typed Name <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />Owner or O ator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br />20. Facilityer <br />Month Day Year <br />T <br />Printed/Typed Name Signature <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A 11/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />