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fJ �� <br /> State of California—Environmemal Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-96) S0@ Instructions on back of 6. Departmentra Toxic Substances Control <br /> rieose print or type. Form designed for use on elite(12pirch) triter. (p Sacramento,California1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFESTCs loo I of f <br /> 3. Gener or' Name an Mailing Address A State Manifest Document Number, <br /> o �itry� RrttE�li 2`� g589 �48' <br /> �rr 1nrtA'( `' <br /> 51�. <Tclj t L-r's r 0t —,-- 37/7 B. state Generators ID <br /> to 4. Generator's Phone (���) 2 3-?,Y 7• <br /> C9V <br /> 0 S. Transporter 1 Company Name 6. US EPA ID Number C.State Transporters 10 <br /> �. D. Transporters Phone <br /> p1 <br /> J <br /> —' 7. Transporter 2 Com any Name 8. US EPA ID Number E. State Transporters ID <br /> Q z <br /> U <br /> F. Transporters.Phone <br /> Q ID <br /> ' <br /> t <br /> Z itys 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Foci •. <br /> r��i f! D <br /> , _.. � olo b 3 I { <br /> O r- Y i'i•1. H. Facility's Phone <br /> Q �,i :c•r ., =' - (51Q)235-1393< <br /> U 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shippirg Name,Hazard Class,and ID Number) No T Quantity Wt/Vol I. Waste Number <br /> Stat <br /> a. l 2- <br /> G =.r <br /> ON N b _ State <br /> ao <br /> v E EPA/Other . <br /> C't R <br /> o A State <br /> o T C. <br /> co <br /> O EPA/Other <br /> 77177-7777LU <br /> R <br /> F— d State <br /> Z <br /> U.1 <br /> U EPA/Other, <br /> LU <br /> Z J. Additional Descriptions for Materials Listed Above - K. Handling Codes for Wastes Listed Above <br /> O <br /> CL Sty•—�E)TPtV- StoraCle Tanlr(s)#17`740_,L7�/ b. <br /> LU <br /> .Tank(s) have Limen inert.ed with 15 / <br /> a <br /> 1bs.Dry Ice Per logo Gallon Capacity, t d. <br /> Z <br /> Q 15. Special Handling Instructions and Additional Information <br /> _ _ - Y�trFd lev- <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, <br /> <I packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> U <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 <br /> economically practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> CL <br /> threat to human health andthq�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 <br /> C waste man geme metho thc7f is available to me and that I can afford. <br /> O Printed/Typed Signature Mon�h Da Year <br /> U y 7.•�� i <br /> Z R 17. Trans o r 'Acknow d ement of Receipt of Materials <br /> LU <br /> A Prin /Typed Name .� igna <br /> Y - <br /> w s <br /> S P <br /> w0 18. Transporter 2 Acknowled entent of Rece; t of.Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> iL T <br /> p E <br /> R <br /> 19. Discrepancy Indication Space <br /> Q F <br /> U <br /> A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of recai t of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Nome SignatLrr:AC Month Day Year <br /> Y �filll Q 5t v � o49b <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/95) <br /> EPA 870.7--22 <br />