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Smro of Colifomic--Environmental Protection Age" See Instructions on back of r 'e 6. Department of Tozk Subaances Car" <br /> Form Appwvad OMS No.2050-0079(Ezpires 9-70.96) Sacramento,California <br /> Please print or type. Farm o'azfpaed fa use on egg(12pikh)%%wiMr. <br /> F Generators US EPA ID No. Manifest Docuanwnt No. 2. Page 1 is not required <br /> in by shaded areas <br /> UNIFORM HAZARDOUS is not equired by Federal law. <br /> WASTE MANIFEST F 4 °f <br /> /Mo <br /> _ L �ta� ,ay A. Yaro MO m (rant Number <br /> r� 3. Generator's Name and Mailing Address J /r sA� yi <br /> 0.Stain Generaia',ID <br /> 4. 7 <br /> S. TromCompanyr 1 Company me <br /> 6. US EPA ID Number Gs Stole TromporNrt ID <br /> gP .2 r . Transporters Ph t <br /> A 018. S EPA ID Number E..Shte Trounsporter's ID <br /> 7. Transpodar 2 ompany Nome _ <br /> s1=. Transporter't Pham - <br /> Na 9,rD'esignated Facility Name and Site Address 10. US EPA ID Number G. Srote Facility's ID <br /> h . <br /> -76 <br /> LA <br /> Cmeai T 17 7uta1 Unit <br /> Z 11. US DOT Description(including PropNo T Procter hipping Noma,Hazard Class,and ID Number) �, Wt/Vol tats Number <br /> Q G< ft U G/ <br /> 3 �aS 1.er/Jcl1G , 6 EpA/char L <br /> o B it ta' �eF <br /> N is <br /> E EPA/ r <br /> A <br /> A state <br /> m <br /> T <. <br /> O FPA/OMer <br /> as R <br /> ZZ Sta e 1 <br /> d 1I <br /> V EPA Other <br /> W _ <br /> N _— <br /> Z 1. Addniorail Descriptions far Above K.Materials Listed Ab ' } / K. Houndlin¢Cede 1w Wartsolisie d Above <br /> s7`12.. °' b r <br /> a <br /> O1!. Specd tfa dlaq bell. tsn and dditional In fo/m tion <br /> lei k— <br /> Wj�X—V— C�f ..)�Lt c..�:fZG fC"' 1 �V ��L / 2— <br /> Y <br /> 16. GENFeATOR'S CERTIFICATION: I hereby sim,lapithat the contents of this consignment aro fully and accurately described above by proper shipping name and are classified, <br /> Q pocked,marked,and labeled,and are in all resSuch in proper condfion for transport by highway atcordhp to applicable international and national govemment regulations. <br /> If I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined Its be <br /> K economically practicable and that 1 haw selected the practicable mesiad of heahnent,storage,or disposal currently available Its me,which minimizes the present and future <br /> N threat to human health and the emirerenenh OR,R I am a small quantity generator, I haw made a gots faith effort to minimize my wast generation and select Ihs beg <br /> sh <br /> W wamen od Pat b OVIEW12me and that 1 can afford. <br /> O Prkted/Typed Name SI month Dy year <br /> p <br /> IF p+ <br /> Z T Tr r I Ackno m ecai of doh / y <br /> (UJI A PrkMd/Typed Name 'T Sigralure, � Y t J. March Day'� Year <br /> R 7 // 0 <br /> F ,J ... r _�(: <br /> 0 18. T r 2 Acknowleclownent of Receipt of Materials <br /> U. T PraMd/Typed Name Signature Math Day Year <br /> OA <br /> yWj 19. Discrepancy Indication Space <br /> U f <br /> A <br /> Z c <br /> I <br /> L <br /> I 20. Facility Owner of Operatcur Certification of receipt of hazardous materials covered by this manil"except as haled in Sem 19. <br /> T PraNd/Typed Name Signature Month Day Year <br /> IF <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A (1/95) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />