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V ! 4- L (es' O'° / +m- , ✓1 sr'o" -t w � 'WT'f <br />State of of Protection Agency .y <br />Form 13MB Noi 2050-0039 9•3D.94) { of S' (� " Instructions on back ` e page <br />b. 61 rDepartment of Toxic Substances contpf <br />or Form designed for use on Wive f 12 %: l <br />LL <br />3: <br />M <br />A <br />4 <br />a <br />aY <br />C <br />} <br />L <br />2 <br />U.C <br />4X <br />W <br />w <br />LL <br />C <br />LU <br />N <br />Q <br />U <br />I� <br />DO NOT WRITE BELOW IS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 0 D <br />DTSC 8022A (12/91) (Generators who submit hazardous waste for transpo out of state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />UNIFORM HAZARDOUS I. rotor's US EPA ID No. <br />Manifest Docu No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />15 PWB PQgUlred by Federal k7W. <br />Cl Al DI 2181114151 91 Al <br />Al 1319 1 7 9 1 <br />1 of <br />3. Generators Name and Mailing Ad mss <br />?AState Manifest 0001""Old k�nbeil" <br />Santa Fe Railroad <br />740 Ca mwaie Road, San Bernadino, CA 92408-3573 <br />cry:,D <br />4. Generator's Phone(209)441-2521 <br />'z 3 - <br />i <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />r--Stc" Traaporfer's fD ar, <br />Eric3sr m, Inc. IC A ID 10 10 1914 <br />16 16131912 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />! <br />E. Sift T y'a fp ' <br />1Z (%I c. i C%!% �'itl G /9 L! fi` a1 S <br />% 1 <br />s <br />9. Facility Name and Site Address 10. US EPA ID Number <br />♦tD*esignated <br />. S. Ecology <br />07 <br />HWY. 95 1.2 Miles S. of Beatty <br />3 INIVIT1330030 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. UnitT <br />, <br />No. <br />TY <br />Quantity <br />Wt/Vot�• <br />a. Non RSA Hazardaw Moat® solid <br />� <br />E��°� <br />b <br />� <br />E <br />R <br />A <br />T <br />O <br />C. <br />d. <br />.;EPA <br />1. adona �� 777,77 77777777) <br />Codes <br />bove <br />for Wastes Usted Ab. <br />d. <br />15. Special Handling Instructions and Additional Information <br />Glavef aid CcWlss <br />24 Hour Contact: <br />NWat r'ke f FC <br />16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of the consignment are fully and accurately described above by <br />proper shipping name and are classified, <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 />If I am a large quontty generator, I 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 />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 />threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br />waste mono ement method that is available to me and that I can afford. <br />Printed/Typed Name <br />kA <br />Signature <br />Month Day Year <br />lh r s- L'✓ . ry' <br />T <br />It <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />Printed/T N e <br />Signature � <br />Month Day Year <br />S <br />0 <br />18. Transporter 2 Acknowledgement of Recei o Materials <br />y <br />E <br />Printed/Typed Name <br />Si nature <br />9 <br />Month Day Year <br />R <br />Gf > <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />20. Facil' Owner or Operator Certification of receipt of hazardous materials <br />covered by this manifest except as rated in Item 19. <br />TT <br />Printed/Typed Na/me <br />Signature <br />Month Day Year <br />DO NOT WRITE BELOW IS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 0 D <br />DTSC 8022A (12/91) (Generators who submit hazardous waste for transpo out of state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />