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asmisotc,alibmic-tvsirmmenbfProtectionAgway <br /> Form <br /> Approved OMB No.2050-0039(Expires 9.3099) See Instructions on back ofPar-- 6. <br /> Please print or type. Form dasfgnd hr vss m elib(I2-pimhf type is - D!partmenl of Toxic Substances Control <br /> Sacramento,California <br /> UNIFORM.HAZARDOUS 1. Gemreso/s US EPA ID No. Manifest Document No. 2. Page 7 I Information in the shaded area+ <br /> WASTE MANIFEST FH is not regaird by Federal law. <br /> - 01 � 6 � 5 17ZG4 I � 1 <br /> `3. GeoeralWs Name ad Vli ddre+s <br /> L+ f+ t L ti1TvV <br /> '7 ^co W <br /> r r ci p y 04 C r r,• B' Stare GenaraM's ID <br /> nA. Gemrobr's Phone <br /> tN 5. Transporter I Company Nome 6. US EPA ID Number C. State Transporter'+ID <br /> m <br /> till <br /> C J S S- 7 .1 -7 � D. Transporters Pk, e <br /> O I'Fa.S Tve'Ie ,slac-t, 1..J 7 q S 4 <br /> GO .7 ) <br /> _ 7. Transporter 2 Company Name S. US EPA ID Number E. Stale Transporror's to <br /> J <br /> QF. Transporter'+Phone <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> - <br /> to,Az Ly: ✓+"C �., <br /> WO H. Facility's Phone <br /> of Pic,..0v jL� '.fy.kc.l C n J ct c 9 ,i G L 5 Z �'to 2iS-1593 <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number 12. Conralners 3. Total 1 d. Vol <br /> p Ir 8 ape FFA e I No. type Quantity Wt/Vol 1. Waste Number <br /> sl--IZ a. <br /> NON RCJK\ 1-.AVrE, Scr[.;ii State <br /> 003 G c ASTE CM: I 1,T.:1:.CC -fn.w. c CZ Tit , O EPA/Oho: <br /> ri <br /> N b. <br /> p S are <br /> E <br /> .p R EPA/Other <br /> a A <br /> g T Stam <br /> n O <br /> R EPA/Other <br /> ac <br /> F d. State <br /> Z <br /> w <br /> V EPA/Other <br /> W <br /> N <br /> - i' 'Conks forWfiltei tfsroA Above - - <br /> Is. <br /> w <br /> d. <br /> 0 15. Special Handling Instructions and Additional Information <br /> F c.2i�A.�•,YrFsss•:...ccf5 ., tr-„n,.•.. ..c. •t � up.,-�. �.t.r:. �...rak c ..... > � c ;.r > <br /> Z <br /> Z <br /> w <br /> Fes- 4 W4.C-s:4c.E.eCV TZ7- .4 <br /> •'' 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper hipring naand a re classified,packed, <br /> la.! marked,and labeled,and are in all respects in proper condition for transport by highway according b applicable international and actions Pme government regulations. <br /> If I am a large quanli generator,I certify that I have a pro <br /> ggtom in place ro reduce the volume and toxicity of warm generated to the degree have determined ro be economically <br /> d practicable and that I have selected the practicable method of treatment,storage,or disposal currently available b me which minimizes the present and future titreat to human health <br /> and the environment;OR,if I am a small quantity generator,I have made a god Faith effort to minimize my waste generation and select the best waste management method that is <br /> tet available to me and that I can afford. <br /> O <br /> r Printed/Typsd.Narm.. Signatory? / / r Month Day Year' <br /> 17. Transporter 1 Acknowld ernes'of Receipt of Materials <br /> K R <br /> sty B PrintedL/yTyped Namt /'Ile Signature �' Month Day Year <br /> 12- <br /> W 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O R <br /> T Prinled/Typed Name Signature Month Day Year <br /> W E <br /> � R <br /> (aj F 19. Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> ( 20. Focili Owner or Operator Certification of receipt of hazardous materials covered 6 this manifest except as noted in Item 19, <br /> T Printed/Typed Name Signature Month Day Year <br /> r <br /> fltss�I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(4/971 <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />