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State of Cvli(ornia—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30 See Instructions on r, 'OF page b. Department of Toxic Substances <br /> Please print or type. Form designed for use on elite jon,*'fch)typewriter. V Sacramento,California <br /> 1. Generators US EPA ID No. Manifest Docomenf No. 2. Po 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS Be <br /> WASTE MANIFEST C� j' ( is not r [�'r,u�4ddl�6y Federal law. <br /> of 1 L:riY1] <br /> 3. Generator's Nopsgnd MJptlipp,Addyst� A. Stall Mondesi Document Number <br /> r q <br /> 2169431 <br /> t'' �)=>�""+'j }- i / B. :7 Generators ID <br /> 4. Generators Phone( ! -1 1 A,�- N2 Q P, <br /> N 5. Transporter 1 Company Name 6. Us EPA ID Number <br /> U1, �g�nqr�,�N �� ,p���[�t C. State Transporter's ID eserved. <br /> a) 081MM111 WeYMK11N1aL TAIL SERI M'J gg gg PO (��) <br /> A ® 9 S Z 1113 6 $ x D. Tronsporter's Phone lMMf=Yii'Mw'7* <br /> _ 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved,) <br /> T-4 V F. Transporter's Phone <br /> j M 9. Des" noted Facili Name and Site Address 10. US EPA ID Number G. Stab Facility's ID <br /> SA rr NL€EN <br /> "'WME) IC A ID 1115 it 141914 1311141 <br /> 'c" C, 1021�31iyQ5a ti'i;a H. Facdiy's Phone <br /> (D o SMJOK CA S5133 C IA 10 10 15 0 4 9 4 3 1 6 1.04U-M <br /> U11. US DOT Description(including Proper Shipping Nam,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> l Z a. No. T C Quantity Wt/Vof 1. Waste Number <br /> F N0offl M <br /> I�Y$IC101f6 Wd€.1@s v.'vrnA 1` S '7 <br /> 3 E b G�t r> _...r r EMfR1lCita <br /> N State <br /> ro E <br /> R EPA/Other <br /> i v A C. <br /> $ T State <br /> ac O <br /> R EPA/Other <br /> i F d. <br /> Z stab <br /> w <br /> U EPA/Other <br /> w <br /> I N J. Additional Descriptions for Materials listed Above <br /> O K. Handling Codes for Wastes,Listed Above <br /> 1 a. b. <br /> all <br /> ! a. all. <br /> a <br /> Z 15. Special Handling Instructions and Additional Information <br /> Z0� B Sr! R 12 s ci�hirF#lh 1�t19 424-43w4 r, 3 �� <br /> r W <br /> ee of 1. lnp a 5' <br /> aa�• ��7f.o3/ <br /> t -s 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are full and accurateri described above by pp <br /> V marked,and labeled,and are in all respects in proper condition for transport by highway according b applicable international and national government re0ulationo.me and are pocked, <br /> 'I .e If I am a large quantity generator,I certify that I have a p ram in place to reduce the volume and toxicityof waste generated ro the <br /> ypraeicoble and that 1 hove selected the practicable method of treatment,steno e,or dis g degree I hove determined ro 6a economicallyy <br /> 1 and the environment;OR,if I am a small quantity a pose)currently available b ma which minimizes the present and future threat ro human healNt <br /> q ty 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 an.and that I ran afford.,, <br /> } Prin Name <br /> _ nature. J / , <br /> V y. u _ a Si 8 es. r,..r 1 A+Lonl'r, ,Day t Xaa <br /> (W'd T 17. Trans 1 Ackn on ac ' f of rials <br /> A Printed/T <br /> R % 4;r1 Stgnat�si'' .,( nAr r�yy,, }Yea <br /> t `JJ Is <br /> - 8 15. ons r 2 Ackrawl ermm t of Receipt of Materials , <br /> 0 T Printed/Typed Name 'Signature Month Day Yeo <br /> N E <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> , — A <br /> C <br /> I <br /> L <br /> i l 20. Facility Owner or Operator Certification of ncei t of hazardous materials covered by this manifest exce t as noted in Item 19. <br /> T Printed/iyped No. Signature <br /> Tr Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A 11/991 <br /> EPA 8700-22 <br />