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Stall of Ce FFarnlo—Environmental Protection Agency <br /> Form ApprovedOMB No.2050-0039(E.piros 9-30-99) - SEE Instructions On back 0090 b. Department of Toxic Substances Can <br /> Fleose pont or type._ form devgned far use on elite(12-pili ewnter, Sacramento,California <br /> yNIFORM HAZARDOUS Generators US EPA ID No Manifest Document No 2 Page I ormation in rhe shaded are.. <br /> is notrequired by Federal law <br /> WA MANIFEST + °f t <br /> 3. Gens_ is Nome and Mailing Address A. State Manifest Document Number <br /> 9943406r.- <br /> B. <br /> 34VSB. stole GeTaplar's ID <br /> h <br /> N 1. General.,s Phan. <br /> n <br /> n 5 T•ansparer I Campony Name a US EPA ID Number C. State Transporter',ID[Rewrved.1 <br /> ofof <br /> p i D. Trantporbi s Phones <br /> m 7. Transporter 2 Company Name 8 U5 EPA ID Number E. State Transporter' ID R ss .[ <br /> r.Q F. Trareporter's Phone <br /> U 9. Designated Facility Name and Site Address 10 US EPA ID Numbs, G. State Facility's ID <br /> :L>Q ONTO <br /> CG <br /> 1 <br /> R+l~� -- - - H. Facility',Phone <br /> '323) 2 —3 56 <br /> 11. US COT Descr otion including Proper Shipping Names `+ace rd�la=s and IC Numbarl 12. Ctmomars 13. Total 14 Lair <br /> U No. Type Omani" Wt/Vol I. Waste Number <br /> '•.+ 'Z = Stals <br /> ?= 352 <br /> 3 E EPA/Other <br /> NIA <br /> o N State <br /> E PHIS WASTE STREAM HAS BEEN MINED EPA/Other <br /> e R <br /> e <br /> Cl1D <br /> A Oynv� . •• r irr. <br /> 1 r 7.,, State <br /> ° K tt�V ��'Ilt'E11 ANGELES, EPA/Orher <br /> of "AS 14F <br /> d _ EiVE ; state <br /> Z LJUA WASTE STREAM AS <br /> w Q�lul1FIFI' 1110 rpqal�uorc is r,ATnAnn33681 EPA/orhim - <br /> U) <br /> U.) <br /> Z) J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> O 11A) Profile4f 290311-09 .2 u S ? b' <br /> Parw <br /> c d. <br /> Z <br /> Z 15 Special Handling Instructions and Additional Information <br /> r <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents.I this consist at are fully and accurately described above by proper shipping name and are classified,packed. <br /> Vmarked,and labeled,and ore In all respects in proper condition far mcnsporr by highway according r°applicable iNernoNonal and national government regulations. <br /> J If I am a large quantity generator ertify that I have a p o9ram In place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable pad than haveelected the p ad6mble method aF treatment,storage,ar disposal currently available to me which minimizes the present and future threat to human hevlth <br /> and the environment,OR lf I a mall quantity orator. 1 have made pad air affair to mm:miza waste qu y ge^ o g my w generation and ,oleo the best waste management method that is <br /> Q available rome and that I can affords. , <br /> } Printed/Typed Name Signature Mo mh Day Year <br /> orV <br /> Li <br /> Z <br /> T 17. ons oyer 1 Acknowled a enr of Receit of snatenals -:� <br /> R ' m <br /> w A Printed/Typed Name ^ lr - _ Signature _ Month Day Year <br /> wR — _ <br /> F fl \ 1 _ , 'I\ _ <br /> A. 0 18, Trumi,airant 2 Ackn°wlecaemenr of Receipt of Maier i ams <br /> IPrinted/Typed Name Signature Month Day Yr., <br /> w E <br /> an an R <br /> U 19 C screpancy Irdlca6.a Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner,a,Opera,,Cerr F,.r.n of receipt of ha.vrdem materials covered by itis-or'e ii,rizl a,noted is Item 19. <br /> T Printed Typed Name Signct.re Month Day Yeor <br /> TLS <br /> DO NOT WRITE BELOW THIS LINE. <br /> )TSC 8022A 11 991 - .. <br /> EPA 8700-22 <br />