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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions On back Of page 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch) 'ter. Sacramento,California <br /> UNIFORM HAZARDOUS 1' orator's US EPA ID Na M nifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST ] of required by Federal law. <br /> of <br /> 3. egneralor';Nq a aO esti q Q�dress ... <br /> ;'i l " Y�IO.{' L.Ii Iq A. State Manifest Document Number � � <br /> ATl"N R00EFi 2" <br /> L OD I B. Slate Generator's ID <br /> A. Generators Phone( I <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tronsporter's ID[Reserved.] <br /> h <br /> p -E7Y I,%t- N - D. Transporter's Phone <br /> O <br /> NJ <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.l <br /> QF. Tnsnsporter's Phone <br /> .,.-1 V 9, Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> �fQ l.il,' 4Y3IF ;.' Iccb <br /> L'"12 L.RAMIENT{l CA >..mss [. " _ H. Facility's Phone <br /> '0 <br /> Q 12. Containers 13. Total IA. Unit 1 <br /> V <br /> 11. UB DOT Description)including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol L Waste Number <br /> Z a. state <br /> 4% NA30fler, FG III ' I) 39:' (EPG#i7 . i <br /> 3 G AQ91.EP(11. S DRAKE c 11 ll { Ifs t� ��/ if i �� �y �� EPA/Other <br /> o N b. State <br /> co E <br /> R EPA/Other <br /> v A <br /> 6 T C. State <br /> R RECEIVED EPA/Other <br /> Z d. MAR 2 1 2006 State <br /> w <br /> V EPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> M 1 OPAL SEfiYdCE CMEH b. <br /> m d. <br /> J <br /> Q <br /> Z <br /> Q 15. Special Handling Instructions and Additional Information ' <br /> ZIn <br /> w <br /> t— <br /> Q 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this corsi9ementare fully and accurately described above by proper shipring 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 nationcs government regulations. <br /> J If I am a large quantiq generator,I certify that I have a progmm in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicallyy <br /> wpracticable 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 heaUh <br /> 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 waste management method that is <br /> available to me and that I can afford. <br /> } Printed/Typed Name SignaFsa`e ( / pAonth. Day Year <br /> w T 17: Transporter 1 Ackn wledgement of Receipt of Materials <br /> wad R Printed/Typed Name Signature <br /> M - Month Day Yeor <br /> Q0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/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. Facility Owner or Operator Certification of receipt of hazardous materials covered 6 this manifest except as noted in Item 19. <br /> 7 PriLnJt j/T dd Name res (/1 Signature /Mlonthh Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> e <br /> ,. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br /> DTSC 8022A(1/99) IGeneratar, who sAnril hazardous waste for Tonsporl outofslate, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.I <br />