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Slate of California—Environmental Protection Agency } .i.'tc'-' !.i - - <br /> Form Approved OMB No.2050-00391Expiree 9-30-991 See Instructions.on back of a 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use oa elite(12-pitch) ter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. General US EPA ID No. "'Ma est Document No 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number ..S <br /> Wdi <br /> 8. State Generator's ID <br /> n4. Generator's Phone I 1 <br /> N 5. Transporter 1 Company Name 6, US EPA ID Number C.Slate Transporter's ID[Reserved.l <br /> h <br /> D. Transporter's Phone <br /> W 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> '0 F.F. Transporter's Phone <br /> �V .. <br /> j.rfi,?slgnFted Fatp I)ty�,,tT -6f l,I c. r C 10. US EPA ID Number G. State Focil s ID <br /> Q r "Ie ye rT tai C ry. <br /> L f— 6.,000 81 li <br /> oSAr,r7AMY-,1 -fQ CA 9:3820 ( ACttl;),:^0il:,,4513 T H. Fariuy.Phone <br /> . . w <br /> Q 17. US DOT Description mdudin Pro Shipping Name,Hazard Class,and ID Number 12. Containers 13. Total 14. Unit <br /> rrr��.-��V p 1 g per Aping 1 No. Type Quantity WI/Vol L Waste Number <br /> state <br /> 3 G Frit U'Z I,) t } DF1 EPA/Other <br /> .. E t '.i <br /> b <br /> N . <br /> p Stale <br /> m E <br /> R EPA/Other <br /> v A <br /> 6 T C. <br /> State <br /> m O <br /> _ R EPA/Other <br /> tY <br /> rw- d. State <br /> Z <br /> w <br /> U EPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> h <br /> w <br /> d. <br /> a <br /> Z <br /> 15..Special Handling Instructions and Additional Information.. r '` "" ' ` "' '- -' "."�:+.'l L, i ;;' r,...r <br /> 00 24t.-IR <br /> Z SCEN�' (IP '�:OUE#[i C4f?fIftr n /,: e <br /> = A P 39 k1 <br /> t- <br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuralely described above by proper shipping name and are classified,packed, <br /> V marked,and labeled,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°large quart( generator,I certify that I have a pror in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> Npracticable and that have selected the practicoble method of treatment,storage,or disposal curren ly av noble to me which minimizes the present and future threat to human health <br /> and the environment,OR, if I am a small quantity generator,I have made a good faith effort to ni viy waste generation and select the best waste management method that is <br /> O available to me and that I can afford <br /> )_ Printed/Typed Name Signature 1 r ' / onth- a Year. <br /> w i Transporter 1 Acknowledgement of Receipt of Materials <br /> ac 1 R <br /> �j q krtinte l/Typed Name Signature " ona Y <br /> N 1 �' - t11 : ear <br /> p <br /> Y <br /> P <br /> QR 18. Trans crter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name Signature Month Day Year <br /> W E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — p <br /> C <br /> I <br /> L <br /> 1 20. Facili Owner or O erator CertiFication of race( t of hazardous materials covered 6 this manifest except as noted in Item 79. <br /> T Printed/Typed Name Signature Month Day Ye or <br /> I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 0 1/991 <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br />