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State of CaliforniaMB No.2050- Protection Agency See Instructions on back o e 6. Department of Toxic Substances Control <br /> r7rm Ap""��OMB No.2050-0039(Expires 9-3a9G) Sacramento,Colilomia <br /> Plryse print or type. Form designed for use on elite(12pitch writer. <br /> 1. Generators US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST {. i 1 'j / t ' : .. ' : 1 .." `f' of I <br /> 3. Generator's Name and Mailing Address f r <br /> Ili 4. Generator's Phone <br /> 0? <br /> O 5. Transporter 1 Company Name 6. U$EPA ID Number <br /> 7. Transporter 2 Company Name � 8.,US EPA ID Number <br /> a <br /> ("� Z 9, Do nal Facility,Nome and Site Address 10. US EPA 11)Number ' <br /> u- <br /> Q 12. Containers 13. Total 14, Unit <br /> D Z 11, US DOT Description fincluding Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity WI/Vol <br /> 16, <br /> w N b. rf <br /> v E ' <br /> C4 R /"Zit <br /> d A <br /> m T c. <br /> O <br /> R ! ' <br /> Z d. <br /> w <br /> V <br /> W <br /> Z <br /> O <br /> a <br /> W <br /> J <br /> Q <br /> 0 15. Special Handling instruction and Addt6rail Information ' <br /> Z <br /> H <br /> -+ 16. f,^sf8 EtATOR'S CERTTRCAATION: I hereby dill that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations, <br /> U <br /> j If I am a kwp quantity generator,I certify that I have a program in place to reduce the voknme and tatciciy of waste generated to the degree I hal determined to be <br /> economically romically prackable and that I haselected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> Val threat to human heath and the environment;O&,h 1 am a small quantity generator,I have made a_ good faith effort fo minimae my waste generation and select the best <br /> wade m method Ihat is available to me and that I can afford. <br /> Month bay Year <br /> 0 Printed/Typed Name Signah%re <br /> U _ <br /> Z R 17. Transporter 1 Acknowledgement of Receiptof Materials Month Day <br /> LU rt Name <br /> g re�'' .- - - ,. �. Year <br /> F Panted yped 5, tofu j Y y; f' *?' <br /> P <br /> . _ <br /> LU D 18. T rter 2 Ackno ement of Receiptof Maferiak Monts Day Year <br /> U- T Printed/Typed Name Signature <br /> 0 E <br /> R I <br /> W 19. Discrepancy hu ication Space <br /> U F <br /> U A <br /> Z c <br /> L <br /> I 20. FacilityOwner or cti rotor Certification of reof hazardous materials covered b this manifest exceptas in m Year <br /> T Printed/Typed Name Signoturo Month Day <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: GENERATOR RETAINS <br /> DTSC 8022A (1/95) <br /> EPA 8700.--22 <br />