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state of California—Environmental Protection Agency <br /> Farm ApproLed OMB No.2050-0039(Expires 9-30-99) See Instructions on back age 6. Department of Toxic Substances Can <br /> Please print or type. Form designed for use an efise f 12-feitch'.4ewr(rer. <br /> \w Socramanta,California <br /> UNIfE�RM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page I nformation in the shaded areas <br /> - ,. is not required by Federal law <br /> WASTE MANIFEST . <br /> 3-G-or r.a,'s Name and Mailing Address A. State Manifest Docbmenf Number <br /> = 9916948E_ <br /> B. Slate Generator's ID <br /> nd. Generator's Phare <br /> N 5. Transporter 1 Company Nome 6, US EPA ID Number C. State Transport.,,10 ganserveA.I <br /> ur <br /> T <br /> o ` _ D. Transporter'YPhone 916 371-5747 <br /> OF 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporters ID IIIrved.I <br /> F. Trvnsporrer's Phone <br /> co <br /> l./ 9. Designated Facility Name and Site Address 10, US EPA ID Number G. Stale Facility',ID <br /> 41T019d 33 ! <br /> . �z <br /> -. - .. .. t - - H. Facility's Phone <br /> - <br /> ,LL (323) 268-5056 <br /> 4T? Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 1 d. Unit <br /> ry�V No. Type Quantity Waste Number <br /> '•t/Z o. Slate <br /> 352 <br /> 3 G _. _ - + •- _. - - < c) EPA/Othesr`7/A <br /> o N b State <br /> a R THIS WASTE STREAM HAS BEEN QUALIFIED EPA/Other <br /> A C. AT THE Store <br /> T D/K ENVIRONMENTAL FACILITY IN LOS ANGELES, <br /> RCALIFORNIA. THIS FACILITY HAS THE NECESSARY EPA/ether <br /> W d. PERMITS TO RECEIVE YOUR WASTE STREAM AS State <br /> Z <br /> QUALIFIED. OUR EPA NUMBER IS CAT080033681 EPA/other <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes For Wastes Listed Above <br /> Q Ila) PrO:iieil '8&5 '? IST 3v 57 b.— <br /> poq r��jjy(7'' <br /> a r Ix ,'3� it-0 F� f jr' ; '' <br /> Z 15- Sp—al Handl nq Instructions and Audit amal lnic—n-on <br /> O <br /> Q <br /> w <br /> F <br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that The c.rli of this consiy eat ore fully and accurately described above by proper shipping name and are classified,packed, <br /> V marked,and 1a6.led,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I am a large gmntiq generator, certify that I hove a program iA place to reduce the volume and toxicity of waste generated to the degree I hay.determined to be economical! <br /> tipracticable and that I h ve selected the practicable method of treatment,storage,or disposal currently awila6le to me which m1 the present and future threat to human heahh <br /> and the environment;OR,if I° v mall quantity gen.rdtor,I have made a good faith effort 1.mmimtze my waste generation and select the best waste management method that is <br /> O available to me and that can affords �. <br /> y Printed/Typed Nome Signature Month Day Year <br /> Z <br /> us t 17. Transporter 1 Acknowledgement of Receipt 6f.Materiol. 11 <br /> f1 Printed/Typed Nom�� d- Signature _ .. ,;Month Day .Year <br /> W S _ r �i <br /> u- B 18. Transporter 2 Acknowledgement of Receipt ,6Matenals - <br /> O T Printed/Typed Name Signature Month Day Year <br /> W E <br /> R <br /> V /9. Discrepancy Indication Space .- <br /> Z F <br /> A <br /> C <br /> I 20. Facility Owner or Operator Certification of recei t of hazardous materials covered by this nlfest except as noted in Item 19 <br /> T Printed/Typed Name i Signature r m Month Day Yea- <br /> r )97.A <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) -- <br /> EPA 8700-22 - - - - - <br />