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State of Colifornio—Environmental Protection Agency <br />orm App a ed OMB No. 2050-0039 (Expires 9-30-99) <br />lease print or type. Form designed for use on elite (12 -pitch) typewriter. <br />See Instructions on back of page 6. Department of Toxic Substances Control <br />Sacramento, California <br />1. To <br />O <br />LO <br />LO <br />N <br />N <br />LO <br />T <br />O <br />O <br />aD <br />J <br />Q <br />J <br />Q <br />Z <br />ce <br />O <br />LL <br />Q <br />V <br />Z <br />i <br />3 <br />N <br />0 <br />ao <br />co <br />v <br />N <br />V <br />O <br />0 <br />co <br />tr <br />LU <br />t— <br />Z <br />I <br />V <br />LU <br />N <br />Z <br />O <br />0- <br />V) <br />w <br />ce <br />a <br />Z <br />O <br />Q <br />Z <br />w <br />t— <br />J_ <br />Q <br />u <br />a <br />N <br />ce <br />O <br />} <br />V <br />Z <br />w <br />z <br />w <br />LU <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />UNIFORM HAZARDOUS <br />tor'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 />C �� L C r' M> k <br />/Of I <br />3. Generator's Name and Moiling Address <br />A. State Manifest Document Number <br />/y��y % 8 <br />1 ter 6�. f ✓ "` / <br />y� <br />B. State Generator's ID <br />A. Generator's Phone C , � <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID Reserve!).] <br />�` a ` y <br />.7 'F C - A, [,/'40 A/ fi f' A, � 1 /� : � � � 6 � 7 / Z-1t� <br />D. Transporter's Phone -yD'wy <br />T <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 Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />Ii L1 "e <br />H. Faci ity's Phone <br />11. US DOT Description (including Proper Shipping Name, 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 />/� /' ``...�� f p� <br />1V - AG.. k G;� / ti-? /6.. t U w S �+ epi c r' la <br />State ! <br />G <br />EPA/Other <br />E <br />b <br />5teie <br />N <br />E <br />EPA/Other ' <br />R <br />AC. <br />gate <br />T <br />O <br />@PA/6"r <br />R <br />d. <br />State . <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes'disted Abo4e <br />C. <br />d. <br />15. Special Handling Instructions and Addit' al Information r <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipping name and are classified, packed, <br />international and national regulations. <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable government <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 of treatment, 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 I am a small quantity generator, I have made a good faith effort tq minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Prin( TyTped Name <br />Sgnaire 4° <br />Month Day DaYrs Year <br />A l.f <br />IL <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />f <br />RSignature <br />A <br />Prince Typed Na t f <br />-- "., / �' , <br />it—t <br />Month Day Ye <br />r <br />-- <br />p1 <br />S. Trons orter 2 Acknowledgement of Receipt of Materials - <br />Month Day Year <br />R <br />T <br />Printed/Typed Name Signature <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />Owner or O erator Certification of recei t of hazardous materials covered b this manifest exce t as noted in Item 19. <br />j <br />rrmteoocili <br />d/Typed Name <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br />EPA 8700-22 <br />