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State of Cal'fornia—Environmemal Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) <br /> Please print or type Form designed for use on elite 112-pitch) , �OStrUCtlOnS on back of page 6. <br /> p J ypewrifer' Department of Toxic Substances Control _I <br /> 1. Generator's US EPA ID No.. Sacramento;'California <br /> UNIFORM HAZARDOUS Manifest DocumenlNo. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST t) v 1 a! is not required by Federal law. <br /> 3��pG�enerator's Name and Mail n Address <br /> 3e'4e161TH PUS 11te., A. Stare Manifest Document Numb` 21535703 <br /> r +ry� r+� n <br /> West. Lear,e Stoo};tors, CA 95214 L 15 J 5 7 U 3 <br /> h <br /> ^:.. I. Generator's Phone 1269 B. State Generator's ID <br /> 5. transporter 1 Company Name <br /> Tt � 6 0 0855 r <br /> aD -!sTr rQ'~Y2Lh}A,0r.` e' 6. US EPA ID Number C. S1 t 1 onsporter's ID[Res__rved.] <br /> IF�si tsl 3FaYtlxern trsli2oz ru s tie ;,an <br /> o Rioma3lc� <br /> �ruaxneeYanc+ jj 3 11 0.1 � D. Tronsporter's Phone <br /> 7. Transporter 2 Company Name y 1 0—w559-•5,(2.5 <br /> 8. US EPA ID Number E. Stall Transporter's ID fReserved,] <br /> U <br /> 9. Designated Facility Nome and Sile AddressF. imnsporter's Phone <br /> Q FrAX SBS( 10. US EPA ID Number G. State Faciliy's ID <br /> Z 1795 Second Street C A D 9 0 3 6 0 0 3 3 9 <br /> LL Perkeltg1r CA 9471(;( H. Facility's Phone <br /> Q CDGB 6 00 y Si0_ 9 <br /> Z a. -5126 <br /> U I1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers <br /> 13. Total 14. Unit <br /> N . <br /> RQ, Hazardous �rreste r Liquid , A',G. S. a. Ty a Quantity Wt/Vol IWaste Number <br /> 3 e �. 1Ra 3082; T}C. 111, (Silver) state 541 <br /> W N 6, f 'r- EPA/Other DG11 <br /> > , <br /> m E <br /> R store <br /> N <br /> T c. EPA/Other <br /> O T <br /> m O <br /> R Slate <br /> sF I d. EPA/Other <br /> Z <br /> i <br /> I State <br /> LL EPA/Olher <br /> w� <br /> J. Additional Descriptions for Materials Listed Above <br /> 11 e- Spe17t x,i,7:8Y' Ocln utAin2rtg-sil�rer a Handling Codes for Wastes Listed Above <br /> N <br /> d. <br /> I5. Special Handling Instmctlons and Additional Information s <br /> DOT pRG 91 tatecc fe equipbroenz,i9i,res t ogle=j F,estticked G'OnVituew Lilt I IfAip <br /> DOT EFtfx l7S TreatabiNq+Group' t rnwes?s+ e <br /> Eme+ger¢�eontsat: 3[0 all-9suG 3rivar'4nnte,i: 1500- 5004pixraterTwetmanq tend ri:22iCR4�8S6.40 <br /> Id. GENERATOR'S CERTIFICATION: Thereby declare that the contents of this consignment are fully and accuralel described above byproper shi <br /> marked,vndiabeled,and ore in all respects in proper condition for transport y highway a¢ordin to a - <br /> yy pp gnameandareclossified,packed, <br /> 8 pphcable international and nvtionargovernmont regulations. <br /> If I ora v large gaanfi generator,I certify that I have a ' <br /> q program in place to reduce the volume and toxicity of waste generated to the.degree I have determined to be aconomicall <br /> practicable and Ihvtl have selected the ra<licable method of treatment storage or disposal current) <br /> and the environment;OR,if I'am a small quantity generator,I have mode a p y available la me which minimizes the yy <br /> available to me and that I can afford, good faith effort to minimize my waste generation and select the best and f um re threat <br /> to human <br /> method thatisPrinted/Ted Name <br /> �""�[,� r' Signature <br /> ".7c �% Month Day Year , <br /> I/.-_- l y <br /> T 17. Trans orterl Acknowled ement of Recei tot Materials '�] L <br /> R led(iyped"Name % - r <br /> 'S . . vk, j{ '. -.r' I� Signature fv <br /> R Prin r J + T Month- <br /> 0 18.E _ • ��' Day Year <br /> P _e <br /> Trans orter 2 Acknowled me-vl Recei t of Materials' <br /> 8 <br /> T Pnnted/iypadNome <br /> E Signature <br /> R -'s Month Day Year <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> L <br /> ( 20. Typed Nome Owner or <br /> Printed/Typed O erotor Certification of receipt of hazardous materials covered 6 This manifest ex<e f as noted in Item 19. <br /> rf <br /> Signature '. <br /> - Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> C 8022A )1/99) <br /> 8700-22 <br />