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Stale of California—Environmental Protection Agency Farm Approved OMB No.2050-0039(Expires 9-30 See Instructions On t 'CIC of page 6. Department of Toxic Substano Please print or type. Form designed kr use on alit ikh)typewriter. Sacramento,Californi UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Do ument No. 2. Page I Information in the shaded area WASTE MANIFEST I r a ' a of i not rEuEirrrSSyFed«allow. 3. Generator's Name and Moiling Addrey''-u1 � 1 � A. SIaM Manifest Decisions Numb« q e. ^ E•e C e f, , iI Vh el.F! & State Generalizes ID n d. Generator's Phots )a-44?Z 1lT' �1 JJf �' b1 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tronsperter's ID(Reserved.) asEMOM k"P#IRONMEKK SWIMS D 9 0 1 4 1 3 2 6 1 D. Transpo ees Phone MIXIM 7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporter's ID[Reserved.)1�/L i Q C� i�h 1.y;-C -t' 3 Z Z C- a F. Transporter's Phone LI�T ,. / _ ":s�esY �V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Slate Facility's ID T � ,f[N� z - - - IHkt W881a (fl iP,4— ,,•,.x'15 sa--,-�o sty 1,-11.c:� IC A ID 10 16 19 14 1914 ' 1 0 Ln W 102,Beopesa Rwd H. Facility's Phone ti° SM JIM CA 95133 IC A 10 10 151914191413 1110 1 IA!45]5010 V I1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Conbiners 13. Total IA. Unit Na. T Quantity Wt/Vol I. Waste Number Z o. Stat'--2r&' Sdid +- E N E r Go, E tel b,); 7 5 4�.. C-r tel J r 7'� Stale ��- - EPA/Other 1 v A 1 Stoke m O R EPA/Other Or A. Sere Z w l./ EPA/Otte. w J. Additional Description,For MaterialsListed Above K. Handling Cods:for WOThs Listed Above Z a, -..6, pmmeTF c d. ZZ 0 15. Special Handling Instructions and Additional info a anon Z 24 Now Eme7my Rosponse Tel.No.t'NEMTFE 1-000.424-9300 DOT ERG 47+- WW protective doing } <s 7 $ tBitt of E.atlirlD# L 1 z Sales Qr&r 4 = a 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment era fully and xcuralely described above by proper shipping name and are classified,pocked, Umarked,and labeled,and are in all respects in proper condition for transport by highway according ro applicable inhrnationol and notional government regulations. II I am a large quontigenerator,I certify that I have a program in place he reduce the volume and toxicity of waste generated to the degree I hove determined h be economic Hpracticable 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 he, and the environment;OR,if I am a small quantity generator,I have made a goad faith effort to minimize my waste generation and select the best wash management method the vatlable to me and that I can afford. r Prin Typed Name Signpteie -`.::> Month Day U � { Z A =w T 17. r I Acknowleagerasnit of Receipt of Materials R w S Printed/T Name . Si awn �, ' ,•"• Manth,. Pay Ws it P _ U- R IBA. er Acknowle ementof «ei tof Materials x 0 E Ptn Name t Sig*ft i J ' � nlb� .fir-.. J Q R ! W E 19. Discrepancy Indication Space Z F J C I 20. Focili Owner or O erator Certification of receipt of hazardous materials covered This manifest except as noted in then 19. T /Typed Name "A nature Month Day Csl DON RITE BELOW THIS LINE. Yellow-. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DISC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 da;