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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30-99) SeeInn- trucflons on back ojftge 6. <br />Please print or type. Form designed for use on elite (12-pikh iter. <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. <br />WASTE MANIFEST' ' Q 91 5 4 � `'r Lt <br />3. Generator's Name and Mailing Address A -`State Man <br />BNSF 55� aq r( ii 8: <br />O 140 E. CAl-;aNE.G11" �l%L�Ik w SANK" 13 tw rrlhaU, t�A 92=808 B. S#ateGene <br />A. Generators Phone ( 909--186-4082 <br />N 1 5. Transporter 1 Company Name 6. US EPA ID Number C-1 State Tran: <br />LO <br />aD <br />O <br />O <br />CP <br />V <br />z <br />0 <br />0 <br />Q <br />• V <br />Z <br />3 c <br />N E <br />O N <br />co E <br />v R <br />v A <br />o T <br />O <br />R <br />LU <br />LU <br />t - <br />Z <br />w <br />U <br />LU <br />N <br />Z <br />O <br />CL. <br />V) <br />W <br />ce <br />J <br />Q <br />Z <br />O <br />a <br />Z <br />w . <br />t - <br />J <br />V <br />Department of Toxic Substances Control <br />Sacramento, California <br />a Information in the shadedareas <br />is not required by Federal law. <br />of , It %'et / :2." t e "? r^ i <br />C(,N J4JL.11_j "k .i i::) YaAs7i'., ¢.sVD. C a'i. A...3 ':a iTg 1 <br />7. Transporter 2 Company Name 8. US EPA ID Number -Ei Stale Trcnsporter`s ID fReseroed.J <br />Tratrspbrterts PhtSile <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility"s ID - <br />CROSBY <br />D <br />CNOSB AND CALERRAN <br />R <br />N <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />1630 WES":z .1 7TIl S PPE x <br />`t <br />tt a acitity✓s Pham <br />U-0 <br />i.t')NGT 1EACIA, CA 90813 <br />C A D 0 a zs 4 <br />Oil 1 9 <br />Name <br />� -4 32'5445,1: <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />LU <br />Q <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />;f Waste Number <br />No. Tye <br />a. pj nry <br />Z <br />_ <br />F <br />A <br />C <br />State <br />6o I1 <br />J rw f r ;7 <br />al D. IP1 <br />D 15 10 <br />EPA/Other <br />b. <br />Signature, `�� <br />Month Day Year <br />leg <br />State r <br />C. <br />DISPOSALWAS <br />WAS R@ <br />PERMRS G TREAT NT o C <br />d. IT FNV T%lFjy, 8y <br />ERA) D S 71�ZVVA 7r ° <br />A r. <br />°V TOy°� FUR <br />Eyy Op <br />TOXIC(In-TES <br />15. Special Handling Instructions and Additional Informationy ' r <br />A" r % <br />EAR A.I'I'z�OPRIATE SA El A EQUIPMNi . B-- <br />iFl. C.,f)I'`t"ZAC'1 : C,W 1 /?E/ilhNT-' DELP 5`DA}' G (909)625-6t545 y C-- <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If I am a large quantiy generator, I certify that I have a program in place to reduce the volume'and toxicity of waste generated to the Agree I have determined to be economically <br />practicable 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 health <br />and the environment; OR, if I am a small quantity generator, 1 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />W avoilable to me and that I can afford. <br />OPrinted/Typed Name J E "j. 4iJ:. % \ 2 F': Signature Month Day Year <br />U <br />Z <br />LU T 17. Transrter 1 Acknowled ement of Recei t of Materials <br />ae <br />w <br />R <br />N <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />`t <br />U-0 <br />18. Transparte 2 Acknowled ement of Recei of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />LU <br />Q <br />E <br />R <br />t) <br />19. Discrepancy Indication Space <br />Z <br />_ <br />F <br />A <br />C <br />I <br />L <br />l <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by thismanifest except as noted in Item 19. <br />T <br />Printed/Typed Name '1 <br />Signature, `�� <br />Month Day Year <br />leg <br />DO NOT WRITE BEL4 W THISIYINE. " <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700=22 produce completed copy of this copy and send to DTSC within 30 days.) / <br />