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w State,pf,California—Environmental Protection Agency
<br />Form Approved bMB No. 2050-0039 (Expires 9-30-991 See Instructions Pn back, 04
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<br />1. Generator's US EPA ID No. Manifest Document No.
<br />UNIFORM HAZARDOUS;'
<br />WASTE MANIFEST $ :
<br />3. Generator, s Name and Mailing Address $ `I ;A A.
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<br />9. Designated Facility Name, and Site Address 10. US EPA ID Number
<br />G. `State Facility's ID
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<br />16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are Fully and accurately described above by proper'hipping name and are classified, packed,
<br />and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
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<br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and roxiciy of waste generated ro the degree I have determined to be economical)y
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<br />practicable and that I have selected the practicable method storage, or disposal currently available to me which minimizes the present and future threat to human health
<br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)
<br />12. Containers
<br />13. Total
<br />Quantity
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<br />14. Unit
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<br />17. Transporter 1 Acknowled ement of Receipt of Materials
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<br />15. Special Handling Instructions and Additional Information
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<br />16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are Fully and accurately described above by proper'hipping name and are classified, packed,
<br />and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
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<br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and roxiciy of waste generated ro the degree I have determined to be economical)y
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<br />practicable and that I have selected the practicable method storage, or disposal currently available to me which minimizes the present and future threat to human health
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<br />and the environment; OR, if I am a small quantity generator, I have mode a good Faith effort to minimize my waste generation and select the best waste management method that is
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<br />available to me and that I can afford.
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<br />17. Transporter 1 Acknowled ement of Receipt of Materials
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<br />Printed/Typed Name
<br />SignatureMonth
<br />Day Year
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<br />18. Transporter 2 Acknowled ement of Receipt of MaterialsF
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<br />19. Discrepancy Indication Space �►3pt t7_ /j L (�
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<br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered is manifest except note -WItem 19.
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<br />DO NOT WR BELOW TATS LINE. �r
<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.)
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