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Cate of California—Environmental Protection Agency d I a <br /> arm <br /> Approved or OMB No X050-0039(Expires 9-30-991 See Instructions on Sack ,ofF <br /> lease grin!or type. Form designed for use on elite(12- <br /> pitch)type er- �' Department of Toxic Su6sfances C <br /> UNIFORM HAZARDOUS ` "�atar s US EPA ID No S6Uar^e^tai California <br /> Manikst Document No. <br /> l � 2. Page 1 in of required <br /> in the shaded areas <br /> WASTE MANIFEST IT � �/ �r} Z 9 is"°t required 6Y Fednral bw. <br /> 3. Generator's <br /> Nome <br /> and Mailing Address U I of ! <br /> MR <br /> P15,6,ft <br /> F l�� 3EGYx� ' /�l�al/f Qq 955 <br /> 4. Generator's Phone <br /> 9 [�' <br /> / <br /> 5- Transporter 1 Company Name 6, US EPA ld <br /> 7. Transporter 2 Company NameEPA ID Number <br /> r <br /> 4. Designated Facility)dame and Site Address 10- US EPA ID Number <br /> i 1. U$DOT Description[including Proper Shipping Name,Hazard Class,and ID Nuaeber) 12. Containers 13. Total ld. Un t <br /> a_ IVE— � �� /-- No. Type Ouunt ty <br /> I—I�} j� Wt/Vol <br /> I40M �i///6 V EP r <br /> C4 N 6- O l T T a <br /> an E State <br /> A EPAldiher <br /> tO T c <br /> m O S►orQ <br /> R EPA/Olher <br /> d, <br /> vL <br /> c F <br /> s.`` <br /> �, :} x <br /> F5. Special Handling Mshudeons and.Additional Information <br /> .Sr <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping name and ore classified,packed, <br /> marked,and labeled,rind are in all respects in proper condition for transport by highway according to 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 toxiciy of waste generated to the degree 1 have determined to be economical)y <br /> » practicable and that I have selected the ractica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if l am a small quantity generator,I have mad.a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> Printed/Typed Name Oar J'jC yet �f Signature Montle pay <br /> �7 /� - year <br /> z rJ _ L —G/ZU <br /> L T <br /> A 17- Trans oder Acknowled.emenl of Recei t of Materials - <br /> A P ed/Typed A - otur Month Day Year <br /> M <br /> P <br /> 1 8 18. Tr ns otter 2 Acknowled emenf of Recei t of Materials <br /> TPrinte /Typed Name Signa ure t. <br /> E Month Day Year -; <br /> R <br /> 19. Discrepancy Indication Space <br /> z F <br /> A <br /> I <br /> L <br /> l 20. Facility Owner or operator Certificatian of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Nom Siynotur <br /> LTy" <br /> Month Day Year <br /> ? 6 <br /> DO NOT WRITE BELOW THIS LINE. <br /> SC 8022A (fL «. White: TSDF SENDS THIS COPY TO DT5C WITHIN 30 DAYS. <br /> A 870p--22 - Ta_ P.O. Bax 3000, Sacramento, CA 95812- <br /> - <br />