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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-991 See Instructions OO bO[I( OF PO90 b. Department of Toxic Substances Control <br /> AL Please print or type. Form designed for use on.1he(121-pitchf y 'er. <br /> Sacramento,California <br /> UNIFORM HAZARDOUS <br /> Victor's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law.• <br /> WASTE MANIFEST of f <br /> 3 Generators Nome and Mailing Address A. State Manifest Document Number <br /> 24826730 LJ.. p°2 �y W <br /> 1 <br /> ... B. State Generator's ID <br /> A. Generator's Phone I 1 <br /> tN 5. Transporter I Company Name 6, US EPA ID Number C. State Transporter's ID[Reserved.) <br /> Q? D. Transporters Phone <br /> C? 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserve .1 <br /> D..y <br /> Q F. Transporter's Phone <br /> V 9, Designated Faaillty'N...and Site Address 10. US EPA ID Number G. State Facility's ID <br /> w Q <br /> Z <br /> N a' "� r_. H. Facility's Phone <br /> O <br /> 11. USDOT Description(including Pre Shipping Name,Hazard Class,and ID Number 12. Contain.,, 13. Total 14. Unit <br /> V P I 8 Per PPi 9 <br /> o No. Type Quantity Wt/Vol 1. Waste Number <br /> Z State <br /> 3 G I r " EPA/Other <br /> o <br /> E N 6. State <br /> m E <br /> V R EPA/Other <br /> e A <br /> o T <br /> State <br /> m O <br /> _ R EPA/Other <br /> ac <br /> d. State <br /> Z <br /> W <br /> V EPA/Other <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 6, <br /> w <br /> ac c. d. <br /> QZ <br /> 15. Special Handling Instructions and Additional Information - <br /> H _ <br /> Z <br /> w <br /> F <br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this conignmenlare Fully and accurate)y described above by proper ship ing 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 notion government regulations. <br /> J If I am a large quantity generator,I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical)y <br /> a_ practicable and that have selected the Practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> ac 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 wash management method that is <br /> ac <br /> O available m me and that I can afford. ' <br /> } Printed/Typed Name Signature ; r' r -) Month Day Year <br /> w _- <br /> (� 6 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w R Printed/Typed N e FT r Signature —. / Month Day Year <br /> P <br /> I Cilia <br /> OB 18. Trans orter 2 Acknowledgement of Receipt of Materials !� -^ - <br /> T Printed/Typed Name Signdhire Month Day Year <br /> y E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z P <br /> _ p <br /> C <br /> I <br /> L <br /> 20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T I Printed/Typed Name Signal... Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 00-22(1/99) <br /> EPA 87700— Yellow. GENERATOR RETAINS <br />