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State of California—Environmental Protection Agency Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of` a 6. Department of Toxic Substances Control Please print or type. form designed far use an elite f i2 pitch ler. q— Please _ a r ior_ CN Q 00 co -4 N V 0 G E N E R A T O R F A C L I T Y DO NOT WRITE BELOW THIS LINE, Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (4/97) (Generators who submit hazardous waste for transport aut-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) UNIFORM HAZARDOUS enerator's US EPA ID No. Manifest Document 2. Page IInformation in the shaded areasu WASTE MANIFESTyl y '." f, <. `' !~i: is not required by Federal law. 3. Generator's Name and Mailing Address A. Slate Manifest bocumeni Number - — - - ,¢ f '. s !,-1) 9 ��;d "..'s`•`Y i . _. ,},.. -"''r7- , t13 tt� ti•a �`�� B. State Generator'sID •, 4. C�erfeF<�1`or{s lahone ( _,Ir '' {+* Li— $ Transporter 1 Company Name 6, US EPA ID Number w' a �' -LL -L, C. State Transporter's ID •,' a. d+5:' D Transporter's Phone s - 7. Transporter 2 Company Name 8. US EPA ID Number "` E. State Transporter's ID - r ,.*�afi' .. ms's`,,; >-� a •,.^ ,r�„ F i F. Transporfer's Phone AA 9- Designated Facility Name and Site Address 10, US EPA ID Number G, State Facility's ID - ._.. H. Facility's Phone 11. US DOT Description )including Proper Shipping Name, Hazard Class, and ID Number) 12. Containers 13. Total 14� Unit Na.. Type Quantity Wt/Vo] L Waste Number a. L^#r sof .:rii . ''yA a x + �z il, t r. •� , .. State FPA/Oth`Sr ��. b. t State : EPA/Olhar CL State EPA/Other d Stole FPA/Other J, Additional Descriptions For Materials Listed AboveK. Handling Codes{orWasies Listed Above t t. r 15- Special Hon&ng Instrudlions and Additional information -7 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, marked, and labeled, and are in all respects in proper condition for transport by highway according to international applicable and nationel government regufaiions. 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 economicoPy 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 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 available to me and that I can afford. Printed/Typed Name pp , V , •' Month Day Year i .4� ��S+ignature ^a`11 I'll �Mi..€_s-,Ft°'a:. �._.f A.—, .. tr"'E r+j1, k P 17. Transporter I Acknowledgement of Receipt of Materials ' Printed/Typed Name Signatures;:' - - ,a , " Month Day Year _VJ. fir. 18. Trans orter 2 Acknowleclement of Receipt oT Materials Printed/Typed Name Signature �T ,.. - - Month Day Yenr MAI 19. Discrepancy Indication Space - 20. Facilit Owner or Operator Certification of receipt of hozordous materials cave ed by this manifest except as noted in Item 19. Printed/Typed Name _ 5lgnoture th Day Year ji 1. F''T DO NOT WRITE BELOW THIS LINE, Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (4/97) (Generators who submit hazardous waste for transport aut-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)