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State of Colifornio—Environmental Protection Agency Am <br /> Form Approved OMS No.2050-0039(Expires 930-96) See Instructions on bepage 6. Department of Toxic Substance <br /> Plasmas prim on prim or type. Form designed for esefie,(12 J ypewritec Sacramento,Calif.mi, <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded area <br /> WASTE MANIFEST /t f is not required by Federal law. <br /> C ;�, _� 8•' of <br /> 3. Generator's Name and Mailing Address ��/ A. State Manifest Document Number <br /> 965299c, <br /> B. State Generator's ID <br /> V <br /> co4. Generotois Phone ( ) <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transpartefs ID <br /> 09 <br /> D. Transporreh Phone <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> U <br /> U <br /> i F.,Transporter'' Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Stale Facility's ID <br /> co <br /> Facility's Phone <br /> U �I. .. <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> CC) ? No. Type Quantity Wt/Vol I. Waste Number <br /> e j = a. Stat <br /> 3 ;Un,. 1,, ,,I,r' rs aures 223 <br /> j ,%y !Ja flr� EPA/OMer <br /> E <br /> mN It. Slate <br /> VN R EPA/OBwr <br /> �S A <br /> bot T <br /> C. stere <br /> O <br /> i W R EPA/OIMr <br /> C <br /> W <br /> Z d. State <br /> Z <br /> U <br /> W EPA/Other <br /> N <br /> Z J. AddWN l Descriptions for Materials Usted Above K. Handling Codes for Wastes Listed Above <br /> a a. b. <br /> N ]�Q <br /> W e✓ 'O-�r.K�+�rY�.�.r.�� ' <br /> vtG)olcr C. d. <br /> Zz <br /> 13. Special Handling Instiucli«s orsd Additional Information <br /> Q ULUVES <br /> Z E'ALHUENCY <br /> W <br /> T. <br /> H <br /> 16. GENERATOR'S CERTIFICATION: I hereby daclaro that the contents of this consignment are fully and accurately described above by proper shipping name and are classifiec <br /> Up«ked,marked,and labeled,and are in all respects in proper condition for transport by highway according In applicable international and national government regulations. <br /> If I am a large quantity generator, 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 <br /> E d economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and futa <br /> N threatto human health and the euviromnent;OR, if 1 one a small gaontity generator, I have made a good faith effort to minimize my waste generation and select the In <br /> ¢ waste management <br /> method that is available to me and that I can afford. <br /> O Printed/Typed Name Sigrygyrc Month Day <br /> I l_ - / <br /> w T 17. Tra no <br /> mur 1 Ackwled amen)of Recmi t of Moterlais <br /> (� A Primed Typed Nanta Sigrobu /{//' Month Doty <br /> s3 <br /> /i <br /> sly 0 III.-Tionsparter 2 Acknewleclsnum of Recei t of Materials _ <br /> W Primed/Typed Wase SignalMonth Day <br /> O E <br /> W 19. Discrepancy Indication Space <br /> U F <br /> A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day <br /> If <br /> DO NOT WRITE BELOW THIS LINE. <br /> 81.e: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAY: <br /> DTSC 0022A (1/95) To: P.O. Box 400, Sacramento, CA 95812-0400 <br /> EPA 8700-22 - <br />