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Stats of Califomia—EnvirenmwIoI Protection Agency <br />Form AppfovQ OMB No. 2050-0039 (Expires 9 30 99) <br />Plaose print or type, form designed for use on elite I I2 <br />w <br />MI <br />�Z <br />i ac <br />—10 <br />A <br />�V <br />7 <br />�3 <br />PI <br />See Instructions on back of 9e6. Depo,masm of Toxic Substances Control <br />-pi,ch) la..rliter. `/ Sacramento, California <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A 11/971 <br />EPA 8700-22 G,eew TRANSPORTER RETAINS <br />I. Genus i s US EPA ID mge No. Manifest Docuent No. 2. PaI Information in the shaded areas <br />U IFORM HAZARDOUS <br />is notregaired by <br />Federal law. <br />WASTE MANIFEST <br />of <br />t 111516121 11 11 <br />3 <br />3. Generahnr s Name and Marling Address <br />z+ �Y <br />�-,1�; � <br />•�1';, <br />y SY <br />RIC:IFLIIU INC. - ;iL•'iIRY 11J460a ::/U NCtIi;1111' JAY INC. <br />4±. <br />sY7 ?1:i0 :+. iA,.)I:\le^.:.F I /UIy C:A 95240 <br />Sbh mm IID „, <br />v <br />d. Generator's Phone I t <br />2.011 307-733r <br />'1. <br />5. Tramporter I Company Name 6. US EPA ID Number <br />tpa -. OD r tiY s <br />dtI`t', <br />uOI: ..i;L UIL C A D t' ++ 2 4 1 7 2 <br />5 5 ;trawl" Men <br />k.. ; <br />7. Trampurler 2 Company Name B. US EPA ID Number <br />T 1 1D <br />e4it:.l':. <br />a.- <br />9. Designated Facility Name and Site Address 10. US EPA ID NumberI <br />a <br />i " f D <br />A <br />* ,r <br />3AYSIffi 11, 11, I.C. <br />21U 1-11XI71i;L i:T,E.i�{/ <br />H fecthly s Pham :... J !fi <br />�1 +t Sy+� <br />�i ''.+.'IYQ <br />°. <br />t.^. '7 fv a ' L Al 1, r' L 'i 3 U 2 <br />2 [ P, 4 Y BI sEf <br />p lincludin Pr Shi Name, Hazard Class, end ID Number <br />11. US DOT Description 9 open Shipping I <br />12. Co. <br />No. T <br />13. Total <br />Quantity <br />14. Unit <br />WI/Val <br />n <br />1 Y' .' r <br />jiAV AKL:JIJj rrAt:1'!: 1,Ii.;U!L) <br />G <br />(:IXPUZ) 0 10 11 <br />Tj :. <br />E <br />N <br />b. <br />? <br />It <br />T <br />O <br />R <br />d. <br />o <br />J71;i Deserlpgaan'� For MaMial1. We" Abtsw ,.. d <br />k; Rn Cede for Wastes Listed <br />15. Special Handling 1.afirartion, wad Addiganal Information <br />i,r FE;C I'RIA, P"G1ixTIVc CI,G'THI::�J <br />"tel?.:I,�;r:,K.� :::,Ilt'ACi: ltC9►�41-3L15" <br />� E. �' �. c.' l�c:..r <br />r r� t ,.. <br />SE:'. ...R.G. 171 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment oro fully and accurately <br />described above by proper shiping name and ore classified, packed, <br />marked, and labeled, and ore in all respects in proper condition for transport by highway according To applicable international and nationargovemment regulations. <br />in place to reduce the volume and toxicity of waste generated to the degree I have determined to <br />If I am a large quantity general.,, I certify that I have o pro ram treatment, <br />practicable and that I hove selected the practicable method o storage or disposal currently available to me which minimizes the present and future threat <br />be economically <br />to human health <br />that is <br />and the environment; OR, if 1 am a small quantity generator. I have made a good faith effort to minimize <br />avolla61e to me and that I can afford. <br />my waste generation and select the best waste management <br />method <br />Prin d/Typed Nama _ <br />Signetere t ;rtj <br />Monds <br />-7 <br />Dogs Yeer <br />i <br />� T <br />_ <br />T <br />17. Transporter 1 Acknovalechelement of Receipt of Materials <br />/ <br />A <br />Primed/Typed Npme .,, <br />Slgnalun, <br />moi' .��,,.. <br />A�otllh <br />Year <br />0I8. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />1 <br />Printed/Typed Nome <br />Signature <br />Montle <br />Day Year <br />E <br />e <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Ilam 19. <br />T <br />Printed/Typed Name <br />Sign.I. ' J <br />Month <br />Day <br />✓e <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A 11/971 <br />EPA 8700-22 G,eew TRANSPORTER RETAINS <br />