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enrol Protection Agency Instructions on back age 6. Department of Toxic Substances Cohn <br /> tp50 0039(EEpinxpires 9-3496? <br /> ann designed For use on efete(12y r. SacrnmmHo,California <br /> NIFORM HAZARDOUS1. Generator's US EPA ID No. Manifest Document Na. 2. Pope 1 Information in the shaded areas <br /> WASTE MANIFEST lCtI7,Q !,S,014 /��� l ! of is trot required by Federal law. <br /> / <br /> 3. Geoer is Name and M 'ling Add s AIX c <br /> �, S'.� �log- - '�[ ' <br /> in 4. Generatar's Phone ) <br /> g5. Transporter 1 Company Name 6. US EPA ID Number <br /> r63 <br /> J <br /> Q7. Transporter 2 Company Name 8. US EPA ID Number <br /> U <br /> -'� Z 9, Designated Facility Name and Site Address 10. US EPA ID Number <br /> Ce ta <br /> 6-7/ 1n,cIle r4 /V -lr!?a1 IAAd f�Z 93 <br /> _�! U 12. Containers 13. Total 14. Unit <br /> 6 Z 11. US DOT Description(including Proper Shipping Name,Hazard pass,and ID Number) Type <br /> Quantity Wt/Vol <br /> .44C6 'k <br /> r't E <br /> co N b. <br /> 00 4 E <br /> C4 R <br /> A <br /> T c. <br /> oQ O <br /> R <br /> W <br /> ~ <br /> Z d. <br /> W <br /> U <br /> LU <br /> W <br /> Z <br /> O <br /> a - <br /> N <br /> W <br /> im <br /> J <br /> 0 15. Special Handling Instrrrefiarn and ' I In��� �Y ` �j ✓f.J,e ,t #^�?/y' f�-7 Q j <br /> < <br /> Z -�-• <br /> LU <br /> J <br /> 16. OENEUTOR'S CERTHWATION: I hereby declare that the contents of this consignment are fully and accurately described abaft by proper shipping name and are classified, <br /> � packed,marked,and labeled,and are in aA respects in proper cord-tion for hansport by highway according to applicable international and national government regulations. <br /> if I am a large quantity generator,1 certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> CL economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> V1 threat to human health and the envirorrnentr OR,if I am a small quantity generator, I have made a good faith effort to minimize my wan generation and select the best <br /> waste m method that is available to me and that I can afford. <br /> }O Printed/Typed Name Signature Month Day Year <br /> U <br /> Z T 17• Transporter 1 Acknowledgement of Receipt of Materials <br /> Vr 8 Printed/Typed Name Signature Month Day Year <br /> Ix S <br /> wo, 18. T 2 Admawled ement of Receipt of Materials <br /> 1 <br /> Printed/Typed Name Signature Month Day Year <br /> O E <br /> A <br /> W 19. Discrepancy Indication Space <br /> V) <br /> U F <br /> A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered this manifest exceipt as noted in Item 19, <br /> T Prin i /Typed NameSignahrrc Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DISC 8022A (1/95) To: P.O. Box 3000, Sacramento, CA 95812 <br /> EPA 8700--22 <br />