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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-991 See Instructions on back of Daqe 6. Deportment of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 112-pitc riter. Sacramento,California <br /> UNIFORM HAZARDOUS nerator's US EPA ID No. Manifest Document h 2. Page I [_��uired <br /> on in the shaded areas <br /> by Federal law. <br /> WASTE MANIFEST of 4 <br /> 3 Generator's Name and Mailing Address A. Slate Manifest Document Number 22758927 5Q <br /> O +i;; ?'r :ir.iik'r;1 17r i i r ( - B. State Generator's ID <br /> urs 4. Generator's Phoner;. }14.1,, j <br /> n - <br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. Slate Transporter's ID[Reserved.] <br /> D. Transporter's Phone <br /> O <br /> oD 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> rw <br /> jJQ F. Transporter's Phone <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> ' H. Facility's Phone <br /> t {F <br /> J <br /> ! U12. Containers 13. Total 14 Unit <br /> ti <br /> 11. US DOT Description[including Proper Shipping Name,Hazard Class,and Ip Number) <br /> No. Type Quantity Wt/Vol I. Waste Number <br /> Z a. <br /> p State <br /> t`ibtl ('. r•`"i i r ;3f�ici.E`i � ,t e'. ;+ 1�1d. i(Ytt -ft'+i? �tt4'f� �':t9 Z <br /> Gli1j EPA/Other <br /> o N b' ] State <br /> E <br /> R EPA/Other <br /> v A <br /> o T C. <br /> State <br /> oQo O <br /> R EPA/Ocher <br /> tY <br /> L" <br /> d. State <br /> 1-- <br /> Z Z <br /> LU <br /> U EPA/Other <br /> LU <br /> 'r' J. Additional Descriptions for Materials listed Above K. Handling Codes for Wastes Listed Above <br /> j1 I <br /> w <br /> Me c. d. <br /> J <br /> v 15. Special Handling Instructions and Additional Information <br /> Z <br /> LU lip I <br /> I— <br /> 16. GENERATOR'S CERTIFICATION- I hereby declare that the can tents of this consignment are fully and accurately described above by per hipping name and are classified,packed, <br /> < marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable iniernational and national government regulations. <br /> JIf E am a large quantity generator,I certify that I have a program in ploce to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> aLpracticable and that I have selected the racticabla method ai 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 small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> C <br /> Q available to me and that I can afford. <br /> } Printed/Ty ed Name t C <br /> ^ ' Sign _.G2.C�/fir r !fonk r Day r Year <br /> f ht.i <br /> g <br /> Z <br /> w T Tran orler 1 Ackn wl emenl of <br /> LU rinle $igri <br /> ei t of Materials ^.---""'w"•'"""L-.-, __ <br /> 54 <br /> Ad ypedNome f ] ature r onllsw $oyeN Year <br /> LU / ,rr !/ <br /> LU P f.t n <br /> LL B 18. insporter 2 Acknowled ement of Recei t of Materials <br /> Q T Printed/Typed Nome Signature Month Day Year <br /> LU E <br /> V) B <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Fuci6ty Owner or O armor Certification of receipt of hazardous materials covered by this manifest exce t 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) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />