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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) \� See Instructions on back of e b. Department of Toxic Substonces Control <br /> Pteose paint or type. Form designed foruse on afire 02yikhf)"'fi/ntec I.I Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Docamenf No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS _ _ is not required by Federal law. <br /> WASTE MANIFEST of ` <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> _pn. r 98891625 <br /> ._ -_ B. State Generators ID <br /> h4. Generators Phone <br /> f <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number _ C State Transporbrs ID <br /> m _ D. vanSpoH.rs Phan. y 204)667-6692 . <br /> 0 <br /> m 7. Tmnsparhr 2 Company Name B. US EPA ID Number E. state Transporter's ID <br /> F. Transporters Phone <br /> 9. Desi RoatadFaciliryfy Name and Site-Addans _ 10. US EPA ID Number G. State Facility's ID <br /> CV Za. ❑ _ T H. Facility's Phone <br /> 12. containers 13. Total 14. Unit <br /> �a 11. US DOT Description)including Proper Shipping Name,Hazard Class,and ID Number) No Type Quantity Wt/Vol 1. Waste Number <br /> V <br /> .�Z r P.._ = ^T r .+2 _,Jr.L- �I�_. 1 _ ?.._ .,_ 5raee�'r <br /> r - EPA/Other <br /> =3: t.. _ <br /> E b Stare <br /> Ot N <br /> m E EPA/Other / <br /> v R <br /> v A state <br /> o T r. <br /> c O EPA/Other <br /> R <br /> w d State <br /> Z EPA/Other <br /> V <br /> w <br /> J. Additional Descriptions for Materials Listed Above K. Handling For Wastes Lis e <br /> Z <br /> Z a. bt9i . <br /> 0 TANK. BOTTOM WASTE <br /> RINSAT£ a. <br /> d. <br /> a <br /> Z15 Special Handling Instructiond_Add Rio all f rmation <br /> Q Yro-. <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate)yy described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition'or transport by highway according to oppli cable International and national government regulc Gons. <br /> V <br /> J I <br /> If am a large quantity generator, I certify that I have a p gram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be conomi<allyy <br /> d pr cticable and that) ave selected the practicable method of treatment,storage,o l disposal currently available to me which minimizes izes the present and future threat to,human heobh <br /> 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 waste management method that Is <br /> 0 available to me and that can afford- %'� <br /> , Month Day f,Year <br /> Prnted/Typesignature <br /> (` <br /> _ .�.. <br /> Z <br /> u' T 17. Transporter I Acknowledgement of Receipt of Materials <br /> R y Year <br /> w A Printed/Typed Name Signature Month. Da <br /> 5 <br /> w P <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O R Printed/Typed Name Signature Month Day Year <br /> T <br /> W E <br /> UiscrE120 <br /> epancy Indication Space <br /> Z <br /> acili Own or O erator Certifico ion of rete(t of hazardous materials covered b This manifest exce f as noted In Item 19. Month Day year <br /> d/Typed Name Sgnature <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A 14/971 <br /> EPA 8700-22 <br />