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Form Approved OMB No.2050--0039(Expire;930-88) Toxk Substances Control Dirieion <br /> Please War or lyps, (Form designed for use on elite(12-r typewriter). Sacramento,Califomm <br /> UNIFORM HAZARDOUS 1.Iffasinralor's US EPA ID No. Manifest `fags 1 Information in the shaded areas <br /> WASTE MANIFEST r Document No. of is not required by Federal law. <br /> 3.�Ge9era�is Nape and Mailing dress ^ y A. Slate Manifest DocIument Number <br /> 1(/ l 4./ Y/N i euM NG Y <br /> / '^ B. State Generalor's ID <br /> <. Generator's Phone ?+) "� ��!M[!C CSI <br /> p 5 Transporter 1 �mpa7 Name a. US EPA ID Number C. State Transporter's ID <br /> % I .� Transporter's Phon <br /> „j 7. Transporter 2 Company Name 8. EPA ID Number E. State Transporter' ID <br /> ao _ <br /> o ��_ . y / / tli Transporter';Pho T <br /> ?t 9. Designated Facility Name and Site A dress to. U EPA ID Number G. State Facility's I <br /> a .L � �r Airy jnA <br /> U H. acility's Phone <br /> 12. Contai s 13. Total 14, I. <br /> O 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Quantity Unit Waste No. <br /> LL <br /> J 1. ; J No. Type Wt/Vo <br /> astate <br /> co LG..` �`*If0 <br /> Z <br /> E EPA/Other <br /> L N <br /> 3 24) <br /> E b. C <br /> State <br /> N R <br /> TEPA/Other <br /> eO <br /> e c <br /> R <br /> Stale <br /> 0 <br /> 0 <br /> m EPA/Other <br /> w d. State <br /> Z <br /> Z t <br /> w <br /> U EPA/Other <br />�NW J. Additional Descriptions for Materials Listed Above <br /> p a. Handling Codes Iw Wastes Listed Above <br /> O <br />�N <br />.7J. M I .,, p*.' C. d. <br /> 2 <br />`0 15. Special Handling Instructions and Adoitifnal Information I <br /> 00 <br /> W Z (' <br /> W <br /> S <br /> f <br /> J <br /> < 18. <br /> U GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> J international and national government regulations. <br /> It I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> determined to be economically practicable and that I have selected the practicable method of treatment. storage, or disposal currently available to <br /> O me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a good <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. <br /> U <br /> IU <br /> Print yp d Name/ l Signature Month Day Year <br /> U // <br /> WTR 17. Transporter i Acknowledgeme t of Receipt of Materials <br /> Z A Prints Typ it Name / Signature Month Day Year <br /> 11141 , i Ad 141N <br /> s e, <br /> LL P ^ <br /> O D 18. Yransporter 2 Acknowledgement cylleceipt of Materials <br /> w R Printed/Typetl Name Signature Month Day Year <br /> N <br /> E <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest exc t as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DHS e022 A(1/87) INSTRUCTIONS ON THE BACK <br /> EPA 8]00-22 YELLOW: GENERATOR RETAINS <br /> (Rev.9-86) Previous editions are obsolete. <br /> Y' <br />