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State of Cnlifornia--Environmgntaf Protection Agency <br /> Form Approved OMB NO.?050-0039(Expires 9-30-99) IOnS On backpge 6 <br /> Pleaso print or type. Form designed for use on elfil 112-p it uewriler. F + <br /> Department of Toxic Substances Contra( <br /> UNIFORM HAZARDOIJFS 1. Generator's US EPA ID Na. Sacramento,Cofifornia <br /> Manifest Document No. 2. Page I Informalion in the shaded areas <br /> WASTE MANIFEST�a C A TJ � � ]. � "7 1. 'y s qI is not required by Federal law. <br /> of <br /> A. State ManiFaso Document Number 22091561 P <br /> LO fO4"Kt�iIfr CA 9:206 4.Iw0Mi151 <br /> 4. Generator's Phone ({s0C) ] ,�;,���-'�,r3J�' B. Slate Generator's ID <br /> ti <br /> 5. Transporter 1 Company Name <br /> to <br /> ap d. US EPA ID Number C.. Slate Transporlar's lD[Reserve .[ <br /> o SHOP HA;r",AIr1.),1 <br /> O D, Transporter's Phone <br /> C? fF3tI{i) 'P�k�� 7+g4 <br /> 7. Transporter 2 Company Nam® <br /> 8. US EPA ID Number E. Slala Tranaporter's ID[Reserved.] <br /> 1 <br /> p� g�tp F. Transporter'a Phone <br /> C$II e tpled�ac'Ifj�iy AsraSite Address 10. US EPA ID Number <br /> Q Y SS�� ��`" G, Stale Facility"s ID <br /> Z 17TH 3T <br /> CIQ 0 1401'G BF°:+At:"L'Ir CA -3001:3 H: Facility's Phone <br /> Ps ll (562) 402-8445 <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number} <br /> 12, Containers 13. Total 14. Unit <br /> Z o Arlt CL•S3ea No. T e Quantity WI/Vol I. Waste Number <br /> _ r Airfinia et (each nest; rxts c3xtx t <br /> t— 1 I, �ag�au ar�r} r 2_.1 r 'LTITI 115{}r (f3{I{3]) <br /> j G Stara 1 <br /> > E i) t) 1 El 1�# Cl tl 2 5 U jS EPA/011STj 01 <br /> 0 N <br /> O <br /> co E ITdW—RCE[A I'IAZA.MIGU�i WAOJTE SOLID State <br /> v R <br /> v A fT 0 7 5 0EPa <br /> C. E r rar <br /> o T <br /> 10 O Stale <br /> R <br /> LU d. EPA/glher <br /> Z <br /> w <br /> V Stale <br /> LU <br /> QV) Addjo,,,,,I D c Irqqpsyf' igrra s t b _ EPA/Other <br /> .r;'7�'�Ii 7r 11?rr ��rK3� 4 p .. I y LiF, #274941 K, Handling Codes for Wastes Listed Above <br /> ]' {, a. b. <br /> ce <br /> C. <br /> O °�lgI�3K� •' �:.TI3 �1�rr+v':Z r`kIT1 I2C;EIQCY - rI2S rl/ t nF .rCONTACT: (800) 746-744911, JL�cRmfi3V <br /> r CA 95206 w <br /> LU <br /> z <br /> ,,. <br /> 1 d. GENERATOR'S CERTIFICATION: I hereby decfareIhaF the contents of 9his cans(gnmani are fully and ascurplely described abov by proper ship ing name and are classified,.packed, <br /> V marked,and labeled,and are in all respects in proper condition for Brans ort b y p <br /> P Y highway according to applicable inrernati nal and natianal government regulations. <br /> IF I am a large quantity generator,I certify that f have a pro®ram in place to reduce the volume and toxicity of waste enerated to the degree f hove determined to be economically <br /> practicable and Thai I nava selected the proclicable method of treatment,storage,or disposal currently available to me hick minimi S�lhe present and Future threat to human health <br /> � and the environment;OR,if I am a small quantity generator,f have made o za <br /> d available ro me and that i can afford. good faith effort to minimize in wast enerati n and Sal Ilse hest vfasfe management method that is <br /> >- Printed/rypdd',N me J <br /> Z T t...) }..,.6 F r'-� <br /> Signature <br /> Montfs DaY Ye r <br /> ut T <br /> Cie R 17. Trans attar 1 Acknowled a enl of Recei t of Materials <br /> Cie N Printed/Typed Ngy�er' r <br /> 2` S ,f/"(I�[ f t Signalure <br /> W q•%1 �' ' onilt <br /> P + Day Year <br /> u_ 0 18. Trans Drier 2 Acknowled amen(of Racei f of Materials ~' ����`� � � *f1 <br /> 7 Printed/Typed Name <br /> � f Signature <br /> Q R Month Day Year <br /> d <br /> V 14. Discrepancy fn_dicafion Space `j <br /> Z F <br /> A <br /> C <br /> I <br /> 1 20. Fpc li Owner ar O stator Certification of recei t <br /> T PuntTyped Name aF hazardous materials covered b this manifest except as noted in Item 19. <br /> ed/ <br /> Signature <br /> Month Doy Year <br /> ADO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) r <br /> EPA 8700-22 Blue: GENERATOR SENDS TH6 COPY TO DTSC WITHIN 30 DAYS. <br /> ' <br /> To: P,O. Box 4OO, Sacramento, CA 95812-0400 <br /> i <br />