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Stab of Califarnia—Envirimmental Protection Agway _ <br /> Form Approved OMB No.2050-0039(Expires 9-30-991 - See Instructions on back of po-= b. Department of Toxic Substances Control <br /> Please print or.ype. form designed for use on @lire f 12-pikhl type Sacramento,California <br /> Ali UNIFORM HAZARDOUS I. Generator's US EPA ID No. Manifest Document No. 2. Page I Information in the shaded areas <br /> WASTE MANIFEST / , ( y snot required by Federal law. <br /> �'f r G� ( 'T' � R � I 7 S ( l of <br /> 3. rater's Name1and Moiling Addr <br /> os <br /> 755,c7 G!) . 11 T H , T <br /> A. Genarobh Phone(_` -;r) ^ - 7p, (.r / ��.�� i <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C Stab Transportar's ID <br /> N <br /> m <br /> D. Trr,poetws <br /> 3h�3`L7-mac. <br /> 7. Trans rbr 2 Company Noma D u <br /> po pay 8. U$EPA ID Number E. State Transporbr's ID ; <br /> Qf. Transporter',.Phone <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's 10 <br /> Q �reJCSc.n inL <br /> i <br /> H. Fociliys Phone <br /> CA 4 1G G 13 Z. (SU- 73;.t34I <br /> V I1. US DOT Description(including Shipping Name,Hazard Class,and ID Number 12. Container: 13. Total Id. Unit <br /> p (i g Proper ppi g I No. Type Quanhry Wt/Vol I. Waste Number <br /> T--!Z a. 46,1 C J IJaugDcvc W7, ,.J Stale <br /> (JOT 15,17— <br /> EPA/Other <br /> 013 E (/. aYrE- GA?—,Y STD I.s Lf T,S mkt G`G Z T ? 1 /7 <br /> �c b. State <br /> 03 N <br /> m E <br /> v R EPA/Olhar <br /> v A a <br /> o T sero <br /> w O <br /> EPA/Othe <br /> r. r <br /> W d. Stare <br /> Z <br /> w <br /> V EPA/OIMr' <br /> w <br /> N 1. Add'nio�al De -pt o s for Maredols Gated Above <br /> 7 - <br /> Y` <br /> ac <br /> J <br /> 0 15. Special Handling Instructions and Adclitional Information e <br /> P: WC?Awry ewM Cu,Zit£c cc' Tc II,%,>r. c.)ss£v wcZks'iA <br /> Z <br /> Z <br /> W r_ <br /> � N;(, fr5[RGEI.C4 Cox.r^.Sr.- �5'Ea5 TL.,a� 2 (S3c S'Z7—S�=`W ECL Tc3 '¢' r74"Y(, <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the osmems of this consignment are fully and accurately described above by propershipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according b applicable international and national government regulations. <br /> J IF I am a large quantiq generator,I certify that I hove a proggram in place b reduce the volume and toxicity of waste generated b the degree I have determined to be economicallyY <br /> d practicable and that I hove selected the practicable method of treatment,storage,or disposal currently available to me which minimizes dm present and Future threat b human health <br /> N <br /> ce and the environment;me and tat I if I ora v small quantity generator, have mode a good Faith effort b minimae my waste generation and select the best wash management method that is <br /> O available ro me and that I can aFford- <br /> y Prinbd/Typed Non, Signature .,, ,. Month Day Year <br /> - <br /> U 1— L-% 1 9 T� � tr_: <br /> W 1 17, Transporter I Acknowledgement of Receipt of Materials <br /> W j bd/Typed Name F Signature Month 'Day, ^Vee <br /> W 0 18. Transporter 2 Acknowledgement of Receipt of Materials ' <br /> TPrinted/Typed Name Signature Month Day Year <br /> W [ <br /> Q A <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> _ p <br /> C <br /> I <br /> L <br /> 20, F"ilitvOwner or O araror Certification of recei t of hazardous materials covered Is this manifest except as noted in Item 79. <br /> j A'mted/Typed Name Signature Month Day Yaor <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(z/971 Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />