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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 pa6. Department of Toxic Substances Control <br />Please pr' t •d+Form designed for use on elite 112-pikhl typ Sacramento, California <br />C <br />n <br />an <br />C <br />C <br />a <br />d <br />L <br />4 <br />2 <br />a <br />C <br />4 <br />L <br />?e:ve°n— 8nl 4-MIll DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR. WITHIN 30 DAYS, <br />DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30' days.) <br />UNIFORM HAZARDOUS <br />7Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />1 1 <br />Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />A L® 8 B 2 5 3 4 4.`�7 —7 <br />7 `('� t <br />of <br />3. Generators Name and Mailing Address <br />i'QCia"I WAST D.S. IND., IDC. <br />A. State Manifest Document Number 22975769 w.:. <br />22 <br />4181 D. MY DR. <br />R. score Generator's ID <br />jU10, Ce 4'',1378 <br />� <br />1•:'6-%p <br />A. Generator's Phone ( =M =24 Lufltt.2et: DAMTEL <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. Stme Transporters ID (Reserved.] <br />EDDiC IRl iiI' D <br />. <br />D. Transpo er's Phone `c Nn. <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. state Transporter's ID [Reserved] <br />F. Tmasporters Phone - - <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. Smtracility's ID, <br />S v <br />R011C El9I90lD�TAI. TEO <br />H. Facility's Phone 0•1aI^3di- 1+211 <br />2N1 BA{ MAD C 5 D A 0 4 4 3 2 6 5 7 <br />Rai PLO an, CA "ww <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number <br />p I' g par ppi g I <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number, <br />No. <br />Type <br />it !S <br />State <br />E <br />�r: tl# B 341257EPA/Other <br />t^ <br />� r <br />V <br />Q ,rte <br />f +�Y <br />t <br />t�J^ <br />'^ <br />N <br />b. <br />State <br />E <br />R <br />EPA/Other , <br />Tc. <br />State <br />O <br />R <br />EPA/Other <br />d. <br />safe <br />EPA/Other <br />J. Addi Y:anal Descriptions for Materials listed Above <br />K. Handling Codes for. Wastes <br />Listed Above <br />a. <br />C. <br />a. <br />15. Special Handling Instructions and Additional Information 24 9. EMU W-' 18i2'S?%EE a: 3 6 <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 />marked, and labeled, and are in all respects in proper condition for transport y highway according a app icable international and national government regulations. <br />If I am o large quantity 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 economica11 <br />practicable and that) have selected the practicable method o treatment, storage, or disposal currently oval to me which minimizes the present and future threat to human health <br />OR, if I I have faith to and select the best waste management method that is <br />_ <br />and the environment; am a small quantity. generator, made a good effort minimize my waste generation <br />available to me and that I can afford:: <br />Printed/ ))gqeeed.. Name l j ,� (/, �J �/''' ' <br />Signat'ure�'' /{ .{1 1 %• {._. <br />jMonth Day Year <br />10,11 <br />lolziJ` <br />T <br />17. Trrsporlor 1 Acknowled ement oL.Rausf of Materials <br />If <br />Prinfei{/Typad Dame <br />Sig2vmre- '/1�J , r - <br />Month Day Year <br />&.1,7 iJ�T s <br />�� /✓( <br />! o z 3 0-3 <br />P <br />0 <br />18. Transporter 2 rscknowled ement of Receipt of Materials <br />7 <br />Printed/Typed Name <br />Signature .- <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Spam <br />F <br />A <br />C <br />I <br />1 <br />20. Facility Owneror.0 "'.-rotor Certification of receipt of hazardous materialscovered b J6is•m^iest exce i as noted in Item 19. <br />T <br />Printed/Typed Norho <br />Signature% f � <br />Manch Day,, Ye ,, <br />?e:ve°n— 8nl 4-MIll DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR. WITHIN 30 DAYS, <br />DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30' days.) <br />