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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-00391Eyrires 9-30-9' See Instructions on be Of Page 6. Department of Toxic Substances C <br /> Pleasb prinl or type. -J Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> �f y� /ry 7 is not required by Federal law. <br /> WASTE MANIFEST <br /> P'C C 4.r 4 f ''Cl 9 / of i IEESS <br /> 3. Genaiatorad I <br /> ung <br /> rte, s s -,y A- Stale Manifest Document Number 2175096.xs 0.A ^^ <br /> B. State Ganeroro/s ID <br /> 1 still A. Generator s P I W <br /> CV 5. Transporter I Company Nama 6. US EPA ID Number C. State Transporler's ID(Reserved.] <br /> n <br /> oA D 9 a Y 4 ! 3 Y 6 Y D. Tran goner's Phone eye <br /> C? 7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporte's ID Reserved.] ieL <br /> fill J <br /> Q c-tl%'n i!,{)(,s.(�l/s7 tl' ° 11 !/ O .l a C L �ri F. Tron:porrer's Phone <br /> C) Designated Facility Name and Site Address 10. S EPA ID Number G- State Facility's ID <br /> rn W'g RftUVt&M94NG,if to r f'r -51-hAee 'osr- �- C A D O f 11419141311111 <br /> a <br /> ti�O 1DGt ifewrl RW H. Faciliys Phone <br /> ° o D s 4 s a a i i-/0"1-M <br /> {"4 U 12. Containers 13. Total led. Unit <br /> I1. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number( No. T Quantity WI/Vol I. Waste Number <br /> N Z State <br /> Harrardbuo Scilid <br /> 3 G i L L1pe b�1 5 J DIM VIOIZ410P Eiga� IM <br /> C`4 N b' state <br /> erne E <br /> Y R EPA/CMher <br /> V A C. Stale <br /> o T <br /> m EPA/Ot6r <br /> R <br /> F d. <br /> SroM1 <br /> Z <br /> V EPA/Odier <br /> w <br /> J. Addl6onol De:criplians for Materials Listed Above K. Handling s for Wastes b. Above <br /> C7V�toir f./ cd <br /> C. <br /> �k Z 15. Special Handling Instructions and Additional Information f <br /> o . <br /> ! z 24 Raflr Efnergel Rasplf a Tel.No.CREMTREC I-0-424-9M <br /> w <br /> DOT ERG 171 Wear pfotK&a ciattgu BID of Lading# <br /> Safes Order# jy FSS <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment ore fully and accurably described above by proper ship ing name and are classified,packed, <br /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according ro applicable international and nationaPgovernment regulations. <br /> If l am a lore <br /> d g quantity generator, certify That I have a program in place to reduce the volume and taxicity of waste generated ro the degree I have determined ro be economical- <br /> to practicable and that I hove selected the practicable method a treatment,storage,or disposal currently available to me which minimizes the present and future threat ro human heals <br /> 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 i <br /> 0 available to me and that I can afford. <br /> r PAnled/Nome Sig ature i s --gyp Month Day Ys <br /> 1 17. Trans Aer 7tcknowled ement of Receipt of Materials <br /> A Printed/Ty _ oNre Ihv,. Day <br /> ,<� Y+e <br /> w S f/ <br /> u- 0 18. T ns orter Kelau led ement of Recei t of Materials <br /> O R Printed/T am _'L signahye !/A�o^rA -9" Y. <br /> sWis N . y� <br /> Q <br /> U E 19. Discrepancy Indication Space l <br /> — A <br /> C <br /> I <br /> L <br /> 20. Fal Owner or O rarer Certification of receipt of hazardous materials covered by this manifest compt as noted in Item 19. <br /> T Printed/Typed Nome Signalure Month Day Y. <br /> /y <br /> DO NO RITE BELOW THIS Lkf <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport our of slate, <br /> EPA 8700-22 produce mmpleled copy of this copy and send to DTSC within 30 doys <br />