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Stare of California--Environmemal Promotion Agency <br /> Form Approved OMB No.2050-0039(Expires 930-96) See Instructions On back of page 6. Department of Toxic Substances Control <br /> Please print or type. Form dedgned for use on elite(12pitc writer. Sacramento,California <br /> UNIFORM HAZARDOUS neratar's US EPA ID No. Manifest D«vmenf%0 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST 14d 100 <br /> T O of <br /> / <br /> 3 Generator's Name and Mailing Address [/ A. Stems Manifest Document Number <br /> 7 ,V �,,-�oC— �7-1 96590 6.0 <br /> n7;"' 4/,C24 p r J, / A B. Start.Ganerabr's ID <br /> h 4. Generator's Phorro �7�ie'�s <br /> S ransporler 1 Company Name 6. US EPA ID Number C. State Tnomporter's 10 <br /> ao /^ <br /> (,� n <br /> /� <br /> /,/'/ //. / D. Transporler's Phorse <br /> GrG Y OOta4 <br /> 7. Transporter 2 Company N me 8. U$EPA ID Number E. State Transporter's ID <br /> OU <br /> F. Transporter's Phone <br /> Q <br /> 9 Dmiugn'oted Fa<il' �m�e/and Site Address 10. US EPA ID Number G State Facility ID <br /> (�J �S 9 !.✓r./-T�77ZAtr.t. H. Facility's Ph <br /> Ltd U / O- y <br /> W 12. Containers 13. Total 14. Unit <br /> 11. U$DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. F Type Ouontity Wt/Vol I. Waste Number <br /> FZ- a. State <br /> 3 G /,/ EPA/Other <br /> o E .l �7 a7 tD / i h <br /> 0) N b. State <br /> a E <br /> R EPA/Other <br /> m T c. State <br /> O <br /> y, R EPA/Other <br /> W <br /> Z d. State <br /> W <br /> U <br /> W EPA/Other <br /> Z 1. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Q. b. <br /> Q. r <br /> K <br /> c. d. <br /> Q <br /> Z <br /> O 15, Special Handling Instructions and Additional Information <br /> ~ <br /> Z <br /> r <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare th the contents of this consignment ore fully and accurately described above by proper shipping rwme and are classified, <br /> Upacked,marked,and labeled,and are in all res in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined b be <br /> —y economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> W threat to human health and the environment;OR, if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best <br /> K waste management method that is available to me and that I can afford. <br /> Printed/Typed Name Signature Mom/Typed Name Signature Month Day Year <br /> EPIC LVCL/lCS/ � , o 2 / 717 <br /> w17. Transparter,1 Acknowled emem of Receipt of Materials / <br /> mh/' Day y=1 <br /> t rM0 N rypme <br /> 2-1 <br /> / <br /> m 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> U. T Pdnbd/Typed Name Signature Momh Day Year <br /> 0 E <br /> it <br /> U) 19. Discrepancy Indication Space <br /> U F <br /> A <br /> Z G <br /> I <br /> l <br /> 1 20. Facility Owner or Operator Certification of recei f of hazardous materials covered by this manifest except as noted in Item 19. <br /> T <br /> Y Printed/Typed Name Signature Momh Dory Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/95) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 To: P.O. Box 400, Sacramento, CA 95812-0400 <br />