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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039[Expires9-30-991 See Instructions on back o{ 9e b. Depa rlmenl of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12 Pitc ricer, Sacramento,California <br /> UNIFORM HAZARDOUS enerator's US EPA Z No. Manifest Document 2. Page I Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and MailErq Address A. State Manifest Document Number <br /> 227589" 53 <br /> 8. State Generator's ID <br /> 4") 4. Generator's Phone I I <br /> CN 5, Transporter I Company Name b. US EPA ID Number C. State Transporter's ICJ[Reserved.] <br /> LO <br /> 00 <br /> D. Transporter's Phone <br /> O <br /> m 7. Transporter 2 Company Name 8, US EPA ID Number E. State Transporter's ID[Reserved.] <br /> J <br /> —+ F. Transporter's Phone <br /> 9 Designated Facility Name and Site Address 10, US EPA ID Number G. State Facility's ID <br /> H. Facility's Phone <br /> JJ <br /> U 1 1. US DOT Description[including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> No. Type Quantity Wt/WalI. Waste Number <br /> Z a. <br /> State <br /> s y EPA/Other <br /> �. 'e7}s:u� 1 � ' <br /> O N 6. State <br /> co <br /> 00 E <br /> R EPA/Other <br /> v A <br /> 6 T C. State <br /> CD Q <br /> R EPA/Other <br /> w d. Slate <br /> t— <br /> Z <br /> LU <br /> U EPA/Other <br /> LU <br /> Z1, AddNonol Descriptions for Materials Listed Above K. Handling Codes far Wastes Listed Above <br /> Q a. 6. <br /> V) <br /> cc c d <br /> J <br /> a <br /> 0 15. Special Handling Instructions and Additional Information <br /> LU t <br /> I& GENERATOR'S CERTIFICATION: I 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 are in all respects in proper condition for transport by highway according to applicable international and nationol government regulations. <br /> If I am a large quantity generator,I 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 economically <br /> CL practicaale and that I hove selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a sma I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> at available to me and that I can afford. <br /> 0 <br /> Y Printed/Typed Name d] f Signatur® ,� �opta� ,,- Joy.� Year <br /> �'.�r1f ; -h:zn..PP ,' )a { y. ,r• } /` � .L. .W_..,Fr„�. l f. <br /> L T `I7. Ironsp, i Acknowled gent of Recei f Materials <br /> R e` + <br /> LU d Prinl d/T ed Name f/ j " Af' J Signature r � ✓ rnths -{Jay Yeay�„ <br /> /` -tl.� <br /> 018. Transporter 2 Ackdo led ement of Recei I of Materials _ <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> U-1 E <br /> V) R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I 20. Focili Chvner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />