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State of Calif.ni.—Er,ilcomenhi Prosection Agency <br /> Fstjp Approii MIINo.2050-0039(Expires9-30-99) See Instructions on back r age 6. Department of Taxis Salanam sCa. <br /> Pease print of Farm designed for use on elite f 12-pihE sires. Sacramenin,California <br /> UNIFORM HAZARDOUS <br /> Generator',U$EPA ID Na. Manifest Dommenl Na �2. t nformatio,in h' shaded areas <br /> is nal required by Federal law. <br /> WASTE MANIFEST t. l <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number 7.-",- <br /> It. <br /> It. State Gatroratars ID <br /> 4. Generator's Phone 1 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID <br /> h <br /> m <br /> ' D. Transporhr's Phone <br /> o _. . _ - - <br /> m 7. Transporter 2 Company Name - - `-- - 8. HS EPA 10 Number - E. Stae s Tronsporter ID <br /> F. <br /> Transporter's Phone <br /> U 9. Designated Facility Name and Site Address 10, US EPA 10 Number G. Stab Fociliy's ID <br /> r—< <br /> Z _ H. Facili s Pho e <br /> LL - - <br /> }�Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number 72. Containers 13. Total' 1d. Unl <br /> ,^ lJ pion lin 9 P PPi 9 No. Type Quantity Wt/Vol I. Wash Number <br /> Z a, State <br /> 3 Cz - . . - ._...., - EPA/Other <br /> o N h Stare <br /> aD <br /> ER THIS WASTE STREAM HAS BEEN QUALIFIED EPA/O he <br /> v A <br /> o T t r s I t .�•.. state <br /> o _ r. S ANGELES, EPA/O her <br /> R :SSApRY <br /> Z dh <br /> _ t'_ ... , ^ � Tr�Soo $ra <br /> f ^FJ�. <br /> V Qlif�_Ir L ,. _ n v�u�: ., t Hi U.: •l}� EPA/Other <br /> w <br /> Z1. Additional Descriptions for Materials Listed Above Jul -vf K. Handling Cade,For Wastes Listed Above <br /> w 21�1zr.r <br /> a. d. <br /> z r�a <br /> O 15. Special Handling Instructions and Additional Information <br /> H <br /> Z - .• _ _ > • ... ._. <br /> W <br /> H - <br /> 16. GENERATOR'S CERTIFICATION:-I hereby declare that rhe consents of this constg m are fully and accurately described above by proper ship mg name and are classified,pocked, <br /> Umarked,and lobated,and ore in oil respects in proper condition for transport by highway according to oppliaa6le international and notionoPgovernment regulations. <br /> J If I am largeqantsy s generator,1 certify that I have a p rin place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> i practicable and that I Gave selected he procticoble methodofam treatment,storage, disposalr currently available to me which ml e the present and Future threat to human health <br /> and the environment;OR, if I a small quantity generator,I hove made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> z available to me and that 1 can afford. <br /> O <br /> y Printed/Typed Name Signature Month Day Year <br /> w T 17. Trani"over I Acknowled emeat of Recei r of Materials ` <br /> IR, Printed/Typed Name: "" Signature Month Day Year <br /> w 8 <br /> u_ 0 18. Transporter 2 Acknowledgement of Receipt of Materials - <br /> fPrinted/Typed Name Signature Month Day Year <br /> w E <br /> Q E <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20. Facili Owner or Operator Certification of recei t of hazardous moreriols covered b this manifest except as noted in Item 19. <br /> T <br /> Printed/Typed Name ,t / Signahcq' Month Day Yea, <br /> J DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (6/97) <br /> EPA 8700-22 -- <br />