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r State of California—Enviionmantal Protection A enc' <br /> Form Approved O,NAB No.2050-0039(Expires 9-30-99} <br /> Ples:se print o type. Form designed For use on elite(12 pitch)typewriter. See Instructions Oh back Of PO9@ 6. Department of Toxic Substances Contral <br /> Sacramento,Cali Fornix <br /> ;Generator's <br /> Nf FORM HAZARDOUS 1 Generator's US EPA ID Na. Manifest Document No. T 2 page ; frFormolion in the sf`c areas <br /> WASTE MANIFEST is nor required by Federal law <br /> of i <br /> T3. Nome and Mailing Address A. Stole Manifest Document Number <br /> _'i.rc ;i',ati''• f'�:Ii_�._r' �' . ,. ,1 �� 1r /'t ,? �3 <br /> ' \i �.1'r,T t Pr,r, B. State Generator's ID ~�; <br /> Lin) 4. G ,enera is Phone 1 I `�••�� <br /> N 5. Transporter 1 Company Name 6. US EPA Ip Number <br /> m C. State Transporter's ID[Reserved.] <br /> O ,..,\',,,;.I{.'y�•..i id- '.k'.' :.1'•� ;;;=r :.;i.,`-'r; 1 � .1.ID. Transporter's Phone <br /> 7. <br /> cp <br /> 7. Transporter 2 Company Noma S. US EPA ID Number E. Stole Transporter's ID(Reserved.] <br /> T J <br /> J <br /> F. Transporter's Phone <br /> V 9. Designoled Facility Nome and Site Address <br /> 10. US EPA ID Number G. Stole Faciliy's iD <br /> Q =%%t •`.�.`i %-.:I I'+ r") 'i:i_1'_ H. Facility's Phone <br /> - cA � r', _i• ,1 ,� i E X3'7?_X41:-;.ii;.;, <br /> U11. US DOT'Description(including Proper Shipping Nome,Hazard Class,and ID Number) 12, Ccnlainers 13 Total 1 d. Unit <br /> Z ° No. Type Ouon.•ity WI/Vol I. Waste Number <br /> �•• - ,„__ .'r::.1<: - _ i..)'.i 'F':_2`'.?: ::' 'fN t State <br /> 3 G _, r• Ivl EPA/Other <br /> 000 � b. r I Slate <br /> aa EPA/Other <br /> o T ` <br /> eco O Stare <br /> R EPA/Other <br /> Lu d. <br /> Z Stole <br /> V <br /> w EPA/Other <br /> v) J. Additional Descriptions for Materials Listed Above <br /> O �(t- .(J+,i n�Fh K, Handling Codes for Wastes Listed Above <br /> a !i?:; tf.,•`.••,.4-,+•.y�'•Sp.'.:3 iii`. 6. <br /> w <br /> oe <br /> Z <br /> O 15 Special Handling Instructions and Additional Information <br /> Q ,_ .lie..tl}'.. ..�......�J IsTi.•r r', iX:.. '�: ,'a., <br /> H <br /> Q16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignmenfare fully and accurately described above by proper shipping name end are classified,packed, <br /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable internation°f and ran onal government regvl at; <br /> ons. <br /> sIf I am a large quantify generotor, I certify that I have a progrom in place to reduce the volume and toxicity of waste generated to the degree I have determined to 6e economicaI' <br /> to practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heohh <br /> and the environment;OR,if I am o small quantity generator,f have made a good faith effort to minimize my waste generation and select the best waste management method thoj is <br /> O available to me and that I can afford. <br /> } Printed!Typed Npme Signature <br /> U I. Month Day Year.... <br /> Transaorter 1 Acknowlod emenf of Receipt of Materials <br /> w A Printed/Typed Name Signature <br /> rA Lu Month Day Year <br /> u- r 1A emenf of Receipt o'Materials <br /> `7Nome Signature <br /> v) TMonth�Dj.yY.., <br /> Vy Indication Space <br /> Z <br /> L <br /> j 20. Fo-;Iity Owner or Operator Certificationof recei t o{hazardous mowicils covered 6X this manifest except as nosed in <br /> T Prinled/Typed Name 5lgroture <br /> Y Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. 1 <br /> DTSC 8022A [1/99] <br /> 'PA 6700-22 <br /> 6 'd TT8E 09t, 60Z� OsseAO aTjja>( CIBO :aT SO SZ GaJ <br />( <br />