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ANSI <br /> rdge E1. Department of Toxic Subslances Contral <br /> Sacramento,California <br /> NO Manifest Document No. 2. Page 1 Information in the shaded areas <br /> 4n r is not required by Federal law. <br /> t :. ,� , IDS r y .! r ,ay � of an JAN 2 9 2004 <br /> _ neroror's Nome apd Mollmg Address A. State Manifest Document Numher <br /> �3:s?a4rnsx f°ii7'f' �I.Af'NL�' ,... 22758927 <br /> 1f!�4t+ iaPr. Ei� aw fagQ'�,x I..caani• ,.;.'. <br /> B. State Generator's ID <br /> L. Generator's Phone r i%0t;3'}�'?'[3'�-(frF�i-1 <br /> c� 5. Transporter 1 Company Nome 6. US EPA ID Number C. Stale Transporter's ID(Reserved,l <br /> rr7 <br /> m <br /> D. Transporter's Phone <br /> 7 Transporter 2 Company Name S. US EPA ID Number E. State Transporter's ID[Reserved.[ <br /> F. Transporter's Phone <br /> V <br /> 9 Designated Facility Name and Sile Address I0 US EPA ID Number G. Sl 60hty, IDep C <br /> L <br /> H. Facility's Phone ,1 <br /> U1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and fD Number) 12. Containers 13. Total 14. Unit <br /> Z o. <br /> - No. Type Ovantity Wt/Vol I. Waste Number <br /> _ Slate <br /> EI 1 EPA/Other <br /> f046 � .. <br /> I eco N State <br /> co E <br /> R EPA/Other <br /> v A <br /> © T <br /> ED 0 State <br /> R EPA/Other <br /> w d. <br /> Z State <br /> Lu <br /> V EPA/Other <br /> LU <br /> cA J. Additional Descriptions for M erials Listed Above K. Handling Codes for Wastes Listed Above <br /> o <br /> a. <br /> C. d. <br /> a <br /> O 35. Special Handling Instructions and Additional Information <br /> a r <br /> Z ! <br /> l JA. r b ' <br /> 16. GENERATOR'S CERTIFICATION: t hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,.packed, <br /> U marked,and labeled,and ore in all respects in proper condition for transport by highway according to applicable internotional and national government regulations. <br /> J <br /> J If I om a large quonlity generotor, 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 economics <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently ovailoble to me which minimizes the present and future threat to human health <br /> and the environment;OR, if I am a smalluantii generator,I have made a <br /> 9 y g good faith effort to minimize my waste generation and select the bast waste management method that is <br /> available to me and that I can afford. <br /> Printed/T ped�Name f 0 f.47 f r Signatuseff y <br /> .Da Year, <br /> Z lr �vz> "r� <br /> -17. Transporter I Acknpwjed emenl of I;BCef t of Materials „re+y •-- <br /> W ¢ prinlec�T ped,N„ame N Y f,✓ s r _ �S7gnature ,!� .~ r.Doy�_ Year <br /> SHS FI �fr r,f Month r <br /> Lu P <br /> QB 18. Trans prier 2 Acknowledgement of Receipt of Materials <br /> Lu T Printed/Typed Name Signature r .F:i Month Day Year <br /> R ANGELES, CALIFORNIA HAS ,I <br /> U F 19. Discrepancy Indication Space APIROPRIATE PERMITS- 'r-J - <br /> C <br /> WASTE STREAM AS QIUALIFIED Old EPA <br /> I NUMBER IS CAT080033681 <br /> E <br /> 1 20. Facility..OWnef 6r Operator Certification.of receipt o{hazardous materials covered by this manifest exce las noted in lien 19.. <br /> T Printed/Ty0ed Naini Signature <br /> Y 1 f f' �', l- IManfh . Day, Year. <br /> DO NOT WRITE BELOW THIS TINE, <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. ` <br /> DTSC 8022A 11/991 (Genera fors who submit hazardous waste far transport out-al-state, <br /> EPA 8700-22 produce completed copy of Ibis copy and sena to DTSC within 30 days.) <br />