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Stale of California -Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) <br />Please print or type. Form designed for use on elite (12 -pitch) typ <br />C <br />C\ <br />W. <br />OF <br />C <br />a <br />4 <br />L <br />4 <br />z <br />C <br />4 <br />l <br />L <br />See Instructions on back of pn6. Department of Toxic Substances Control <br />Sacramento, California <br />DTSC. 8022A 0 /991 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THI5 LINE. <br />Yellow: TSDF SENDS THIS COPYTO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-oF-state, <br />'.produce completed copy of this copy and send to DTSC within 30 days.) <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />ALI <br />UNIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />; L 10® 1215131 41 4 5 <br />of t <br />3 Generator's Name and Mailing Address <br />A Stare Manifest Document Number ♦ } a ' .'n <br />it <br />TIld. iRf.. <br />8.-5tate. Generato/s ID <br />A G nerator's Phone ttfa n ,_ n,-_+ 'man `t1.'oc <br />5 Transporter 1 Company Name -- - b. US EPA ID Number <br />C. State Transporters ID [Reserved.] <br />D. Transpcner's Phone <br />- YwvrurnfyAmSAi. T3C$. 3 J � - -`' <br />S = <br />7 Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />I. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facitry's ID. <br />9 <br />T <br />a�txC T $eIYIftON!FA-9f[s s H. FacilityPhone- <br />3CB <br />LL n <br />ant.4. mze n e 12, Containers 13. Total 14. Unit <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) No. Type Quantity Wt/Vol L Waste Number' <br />.State <br />-s�a+mryt <br />EPA/Other.. <br />%TM"Chia! Y'^ <br />M,.i -avid <br />E <br />N <br />- s �+ u :r. <br />6 000-NCdA SAYAUDOUS NASTI LIQUIi3 <br />state <br />E <br />(130vo:rYPP.OPLym BLYCOLI <br />EPA/Other <br />A <br />rii ur .acir.101 <br />state .... <br />T <br />a'SOM-Rea 0Ad1mous agan SOLdU <br />O <br />e <br />jACr`1`ORBAI ;COHOPAP3 iROU-um ;iib] <br />_ <br />EPA/other <br />R <br />e <br />fn a'i (119 <br />h , i:. :, <br />d. <br />State <br />- <br />EPA/Other <br />1. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />i <br />o <br />b. <br />d. <br />i <br />s <br />15. Special Handling lnsbuctions and Additional Information d y((, $td,R1�'"s�lff'.k RI3sPi�'liT{uA a S %ki9i8i4`i.'�bt4 Xit:73L <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, <br />for by highway to applicable international and national government regulations. <br />marked, and labeled, and are in all respects in proper condition transport according <br />If I am a large gaanlity 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 ecanomically <br />a treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />practicable and that 6have selected the practicable method <br />OR, if I I have made a good faith effort to minimize my waste generation and select the best wastemanagement method that is <br />and the environment; am a small quantity generolcr, <br />available to me and that I can afford: <br />Printed/Typed Name <br />Signature �' ter/ / <br />Month Day Year <br />T)a, <br />! <br />,�artsA <br />U Yip "J 1,5 <br />it <br />rti <br />.-'�"' sr`.- <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />/ - <br />A <br />Printed/Typed Name 1 <br />5' nater�/_ _ <br />Month D Year <br />ry ^ G. <br />v S <br />3 <br />,apt <br />Ol / <br />P- <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />� <br />7 <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />j19. <br />Discrepancy Indication Space <br />F <br />= A <br />C <br />L <br />Facility Owner or Opera or Certification of recei t of hazardous' materials <br />covered bhis manifest except as noted in Item 19. <br />120. <br />T <br />Prinled/Typed Name <br />Si t Month Day Year <br />9nature r d <br />Y <br />DTSC. 8022A 0 /991 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THI5 LINE. <br />Yellow: TSDF SENDS THIS COPYTO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-oF-state, <br />'.produce completed copy of this copy and send to DTSC within 30 days.) <br />