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Stare of California—Environm ucal Protection Agency <br /> Form Approved OMB No.2030-W39(Expires 93694) See Instructions on bc"bf page 6. Department of Toxic Substances C <br /> Please print m type. Form designed For use on elite(I*h)typewriter. Socramenlo,California <br /> Is UNIFORM HAZARDOUS 1. Generators US EPA ID No. Manifest Document No. 2. Page 1 1.Manahan in the shaded areas <br /> WASTE MANIFEST r of <br /> is not required by Federal law. <br /> Din r � s�.3 (� <br /> 3. Generator's Name <br /> O SG de iLl ! i yMailin ddresal <br /> " A. State Nwnifest Document Nu r <br /> '7L /O1Zp/0 2 <br /> _ 9 131 967 <br /> QL , `IZ'� j y,} B. Slot.Generator',ID <br /> 4. Generatoro e( � v <br /> © F 2 <br /> 1 C J <br /> 0 3. Transporter I Company Name 6. US EPA ID Number G Slate Trans 11 <br /> s 10 <br /> A 0111,124 ,/1/1 <br /> '5 D. Tdm,podcur' Pho <br /> 7. Transporter 2 Company Name 8. US EPA ID Number / E. Stale Transporter',ID 7 O <br /> Qi <br /> U <br /> F. Transport.i s Phone ,, <br /> (D G 9. Designated Facility Nome ands Site Address 10. US EPA ID Number G. State Facility's ID <br /> f 33QJ�3� H. Facility's Phone <br /> Ma 3 3 !u 7;Z =TM.114� <br /> �U 12. Cont11. US DOT Description(including Proper Shipping Name,Hazard Class>and ID Number) No. . Wast Number <br /> 1-0 Z � Statr`i E I / u CA C�/ ��I OPA/Other <br /> m N b.00 E rat <br /> R EPA/OMer <br /> d A <br /> cp T c <br /> O SIM. <br /> R <br /> ILI EPA/Other <br /> i- <br /> H- <br /> Z d. Stet <br /> U <br /> W EPA/Other <br /> V) <br /> OJ. Additional Descriptions for Matnals Listed Above K. Handling Codes for Wastes Listed Above <br /> d. <br /> 4= <br /> Q15. Special Handling ln.b.cTions and Add nonalInf—ora n r �' '- <br /> Z ��4? elacly C., ev a : C�-c>9) �6 7- 6 O5� <br /> Q 3i <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare thdf the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Packed,marked,and labeled,and are in all respects in proper condition for transport b highway according to applicable international and notional <br /> Q P P Y 9 Y 9government regulations. <br /> U <br /> J If I am a large quantity generation, I certify that I have a program in place to reduce Me volume and toxicity of waste generated to the degree 1 have determined to be <br /> economically practicable and that I have selected the practicable method of treatment, storage,or disposal currently available to me which minimixm the present and tutors <br /> Hthreat to human health and Me environ enl; OR, if I am a small quanli generot ve made a ood int effort to minimize my waste generation and seta the best <br /> waste mono me6 Mod M is avail a and I c uffor <br /> 0 Prinl.ui/i'yy�d No •1 Cx <br /> lu iret . i rwNra Month Day Year <br /> A <br /> Z 1 17. Tran oder 1 Acknowle amens of Recei 1 of at.,ur+ <br /> W A Printed T ad N me <br /> Ur N / YP Signature Month Day Year <br /> W s ; e— <br /> W f <br /> F a I8. Tran er 2 Acknowle ement of Recei t of Materials <br /> W i Printed/Typed Name Si lure <br /> LL E Monts Day Year <br /> O <br /> W 19. Discrepancy Indication Space <br /> N <br /> Q F <br /> U A <br /> Z 1 <br /> ' — k <br /> 1 20. Foacility Ov nor or opeorstrux,Codification of mestizo at hazardous materials covered by this manifest excenst as noted i.4 <br /> m 19. <br /> T Printed/Typed Nama Signature Mo M Doy yea <br /> 9 / <br /> c-G <br /> DO NOT RIE 141.0illf LINE. <br /> White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 877000--22 <br /> DISC 0 (9/93) To: P.O. Rex 3000, Sacramento, CA 95812 <br />