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`State <br />7.,) 4-4,15 01 1-1 U t ji <br />x <br />ofCe�onxo-�nwr Agency v ,/` <br />Form Approved OMB No. 2050-0039 (Expires 9-3494) See Instructions on pack AL page 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on ePiro (1? r. Sacramento, California <br />®' <br />1. Generator's US EPA ID No. Manifest Documenr No. <br />UNIFORM HAZARDOUS <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />is not required by Federal law. <br />31 <br />of <br />3. Generator's Name and Mailing Address <br />0 <br />_ R \ <br />�. 'rJfafa x <br />e j <br />4. Generator's Phone ( r.r 4 r ; ". ` r <br />00 <br />�j <br />fO7 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />MRA <br />; Sh#i fi' r <br />r, <br />f <br />--� <br />7. Transporter 2 Company Name - `8. US EPA ID Number <br />Q <br />MZF <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />n <br />W) Z11. <br />US DOT Description (including Proper Shipping Name, Hazard Class, and 10 Number) <br />12. Containers' <br />No. <br />Type <br />13.-"' 1 <br />Qua <br />14. Unit <br />Wt/Vol <br />= <br />-/?so <br />11 <br />00 <br />N <br />b. <br />.. `�.. <br />A <br />0 <br />T� <br />O <br />�. <br />r <br />r, <br />ce <br />LU <br />Z <br />d. <br />f��,fi�„ •'`. <br />W <br />V <br />FAQ s <br />LU <br />Z <br />O. <br />J. Additional folmater"'thied Above; <br />L '60Mvac1° .► i <br />AL Handling Codes4or Wad" <br />a <br />Usted , A" <br />b. <br />xi <br />W <br />Z-..; <br />c. d. <br />® <br />15. Special Handling Instructions nal Infor <br />Q <br />Z <br />_. <br />U.) <br />-n <br />16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br />q <br />packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable federal, state and international laws. <br />V <br />..e <br />If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br />J <br />economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br />y�y <br />threat to human health and the environment; OR, if 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br />waste mane ment method that is available to me and that I can afford. <br />Q <br />Printed/Typed Name <br />Sigrwfirre <br />Month Day Year <br />V <br />-: <br />ID <br />Z <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />to <br />p <br />N <br />PrintLdjTyped Name <br />Signature <br />Month, Day Yea1 <br />r <br />S <br />.., %..! A - try <br />;/; <br />! �i <br />11 <br />WR <br />=:ZW <br />18. Transporter 2 Acknowled ement of Receipt of Materials <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />O <br />a <br />N19. <br />Discrepancy Indication Space <br />F <br />V <br />A <br />Z <br />_ <br />C <br />I <br />�y <br />L <br />I <br />20. Facility Owner or Operator Certification of receipt of hazardous materials <br />co red b this manifest except as noted in,Rem 19. <br />T <br />Pete Typed Name <br />Sig e/ <br />vt] <br />Month Day Year <br />- , "e? ;Z� / I ( <br />1/ 1 77 <br />DO NOT WRITE pdbW THIS LINE. >. <br />Yellow: . TSDF SENDS' THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (12/91) +�' _ Generators>who submit hazardous waste for transport out -of -stat , <br />EPA 8700-22 Oroduce completed copy of this copy and send to DTSC within 30 days.) <br />