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term Approved UMB No.2050-00391Explres 9-30991 See Instructions on bark a1 O e 6, <br /> please print or type. Form designed/or use on elite(I.' h)ypovrim, P 9 Department of Toxic Substances C <br /> _ Sacramento,California <br /> UNIFORM HAZARD I Generator's US EPA ID No. Mae lest 'aec eat No. 2. Page I Information in the shaded moods <br /> WASTE MANIFEST !: ;1 t:; i] {) ) _L 1i +i 2 Ij g ;j 1) + ) al required by Federal lav <br /> oIf <br /> 3. Gensoalor's Noma and Mailing Address <br /> A. Store Manifest Document Number - /�/1 IE /�.}s• <br /> LA f-1 ,A NO t ?'Af2&R91 ti; !'11"" 3`Vf/T1 IV13 <br /> !' f E° 1301, Ci131 ;S 11 1, +• 1.s <br /> h t.). 7e.. , , 1V 1,t'Y, `A !1.s(' a B. State Generoar'J ID <br /> N d. Generator's Phone (�:,i� N M,64#11 <br /> a7lN 5. Transporter I Company No 6. US EPA ID Number C. Sate Tronsporler's ID peserved.l <br /> m <br /> P11,+{d 1`.;1i i)!1 1 i !! ri .;i l f / �t D. Transponer s Phone <br /> ;' r* zns rt;r�; sz <br /> 7. Transporter'2 Company Name 8. US EPA ID Number s Et-tote Transporters ID[Reserved.] <br /> CDQ F. Trcesporter's ph.. <br /> Lou 9 g 1 d Po iii m be Address 10. US EPA ID Number G. SateFacil N's ID <br /> d <br /> AMID ,:;{I v'1'.iC .;F'1�IN('r:, I "I tjstg l.J i`J ti g j !) „ ,;' ;I r1) -! ii .! H. Fadlily's Phone . <br /> MU US DOT Description(including proper Shipping Nome,flaccid Class,and ID Number) 12. Contalnen 13 Taal 14 Una <br /> V' No. Type Quantity Wt/Vol I I. Waste Num6er <br /> Q')= a1,10T4 �E.:i;/1 : i1S.".ftkl +T:)t l'> tfll/i ;)1 I.li)1.111) stag 221 <br /> EPA/Other <br /> E b 1 i 1 C" <br /> W N <br /> E Smite. <br /> C? <br /> RA <br /> EPA/Ober <br /> a T <br /> O C. <br /> Stae <br /> R EPA/Odser <br /> z <br /> ti d. <br /> Z State <br /> w <br /> U A/Other :.til: <br /> w Fd a'.tjy.. <br /> Z J. Additional Deseri tions(. Materi Is Listed A6o ,� , esT+ ng, fa aslr:W r v ' <br /> Z rnrksr�rrciMwe►sY <br /> w R1fVSATEy` <br /> Od <br /> Z <br /> 0 15. Special Handling Instructions and Adddianal Information <br /> Q llyf'f2t)PIt1A1E- F'1�f)1f_t; S{VE. 1:1.OrT1}NCi J013S(1'E. <br /> Z )'cGf_tt(''1 f;Of li l(:7' ('!t)U)dieii'-tl!3f))1" 1611 :i. Aft )D:)F27 WRY <br /> as, 4Fi1 [7'R (11 111 i1'f.'( CTL11+1, L.:A El`sxlii: <br /> Q16, 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 national government regulations. <br /> If I am a large quontiq generator, certify that I have a program in place to reduce the volume and toxicityg degree I have determined to be econanicoll <br /> N procNco6h,and that I Neve-se:ected dm practicable mashed of treatment,storage,or disposal current) avoilble to me which minimizes he "Y - <br /> ond he environment;OR,if I am a small anti 8 Y present and Future threat to human heaun— <br /> available to me and that I can afford, quantity generator, have made a mod Faith effort to minimize my waste en<rofien and select he best waste management method that is <br /> SignalurMonh I Da <br /> (� T 17. Transporter 1 Acknowled emenr of Recei I.oF.Maarials v' / <br /> R <br /> sd a <br /> Printed/typed NameSigndtore •�..; t'/ . i;_ �_. nrht gay ,,., vYaor <br /> a- 0 18. Tran rrer 2 Acknowled emenr of Recei t of Materials <br /> 0 I Printed/Typed N <br /> w E ame Signamra Month Do Year <br /> h R Y <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> _ p <br /> C <br /> I <br /> L <br /> 1 20. FacilityOwner or Operator Certification of receipt of hacardous materials covered b this m=e,ttalem 19. <br /> T Printed/Typd Name /Y 1 l SignaNreJ • _ Month Days. SIf., n <br /> DO`NIOT'.WRITE BELOW THIS LINE. <br /> DISC 0ll/99) UJ T/,y w <br /> EPA 87700-0— _22 S / L/l�(�/ V/`) T."..:NSPC F7.=F nET1;r15 <br />