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State of Califomin—Emimsm.mal P,.twfi n Agency <br /> Farm Approved OMB No.2050-0079(Expires 9]696) See Instructions on back of ge 6. /ao jh peportmem o1 Toa$u6aares Gntrol <br /> Ceme print dr type. Form designed ler use an euro(IlpirchJ riror. ,� V Socramemo,Cnlifoma <br /> UNIFORM HAZARDOUS 1. Generators US EPA ID No. Manifest Document No. 2. Page 1 ntormation in the shaded areas <br /> is rivet required by Federal law. <br /> WASTE MANIFEST C 01 ► <br /> 9. r' Ne aman Mailing Address A. State Manifest Document Number <br /> sell ^_.^ r arrfEUT c7ns 21 95893'9'48 <br /> N dif f" w14y B. State Generaror's ID <br /> D i ttu<TCf A J. 5QC(4 --37/11 <br /> .. Gmxrato;s Phone03 ,9/61 — Y 7. <br /> g5. Transporter 1 Company Name 6. US EPA ID Number C- Stare Tromp-,ter-ID <br /> maD. Tramporter's Ph. <br /> 5i0 a?3 <br /> Q7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporters ID <br /> U F. Trompoaers Phone <br /> Z 9. Designated Facility Nome and Site Address 10. US EPA ID NumberG, <br /> Stale FadRty's ID <br /> Er <br /> Q255 Pf,rr Gi`i 1. H. F=''6ry's Phoria <br /> G <br /> C,ich (510)235-1393 <br /> U <br /> I1. US DOT Description incbdin Proper Shi Name,Hazard Class,and ID Number) I2. Containers 17. total W Vol <br /> Z P ( gFRi°9 No. T Quantity <br /> \sit/Vol I. Waste Number <br /> a. <br /> = Start12 <br /> J1 3 N; '..— '-1 i1_s yr ..: <br /> IS EPA <br /> E <br /> y * = P <br /> w N b. State <br /> m E <br /> EPA/Orlser <br /> < R <br /> CI A <br /> T State <br /> oro n:. <br /> 0 EPA/Cather - <br /> R <br /> w <br /> Z d Sta e <br /> Z <br /> W <br /> U EPA/Oder <br /> W <br /> N <br /> Z J. Ad&tknal Descdp8ons fen Materials listed Above - � t '?' }-`"' - K Handling Codes for Wastes Listed Above <br /> Qty.�_IInpty Storage Tan} (s)#�7Z/�))�,/77 O f b' <br /> Tank(S) have been inert.ed with 15 / <br /> a <br /> 1bs.Dry Ice Per 1000 Gallon Capacity, t d. <br /> Z <br /> O IS. Special Handling Instructions and Additional Information <br /> _! A cf :• •1 1 _a' iif� s <br /> Z . , . 1. _ .cS WA(KJ _- 9L/t- k,71 <br /> _ �1rft3 mer <br /> t- <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment arc fully and accurately described above by proper shipping name and are classified, <br /> Qpacked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable imernarianal and national government regulalians. <br /> U <br /> If I am a large quantity gmmrato,, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> a <br /> 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 /> N threat to human health and environment; OR, if I am a small quantity generator, I have made v good faith effort to minimize my waste generation and select me <br /> best <br /> M waste mon geme metho d' is available to me and that I can afford. <br /> O Primed/Type Signature Mont D Year <br /> 0 <br /> Z 17. Trans cknow dement of Recei tot Materials <br /> A Prin typed Name r„ i9 ea <br /> n <br /> W 5 <br /> � r <br /> w C 18. Transporter 2 A<knowkd a xm of Receit of Materials <br /> n Primed/Typed Name Signature Month Day Year <br /> LL 1 <br /> O i <br /> W 19. Discrepancy Indication Space <br /> us <br /> Q F <br /> l A <br /> Z C <br /> 1 <br /> L <br /> W�i== <br /> ai t of hazardousmaterials covered by this manlfea except as noted in Item 19-T S=gnature� Mo4 Day '1 year <br /> 1 7� 91 <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (I/95) <br /> EPA 87W-22 <br />