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to of California—Environmental Protection Agency See Instructions on back of <br /> rm <br /> Approved OMB Na.2050-0039 lExpires 9-30-99} � 19r3 Department of Toxic 5 _ control:; <br /> Sacramento,C <br /> ease print or type. fordesigned for use on elite f 12-pitch(type <br /> m ! <br /> - - - - - 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shades <br /> UNIFORM HAZARDOUS is not required by Federal <br /> WASTE MANIFEST C A p 9 8 1 6 3 0 4 1 118 2 0 9 7 of 1 <br /> State Manifest um <br /> 3_ Gene rator's Name and Mailing Address <br /> A..= DocenFNym6e.r <br /> PzC t .:.�;. 22095( <br /> P0 BOX 5095 ROOM #3 000 B_StoteFiepT'eratar`s.FD '. - "- <br /> A. Generator's Phone PAN N CA 94583 (7Z5 )113- I'TIG.6 _ <br /> TION �[ 6. US EPA lD Number <br /> N er " .... 748 - <br /> m CAD 0 5 3 5 4 T 9 9 r5 �.",T anspartef 5 Phoria (408.x'2(]8-1196 <br /> PENMIATION, INC- <br /> 7. Transporter 2 Company Name 8. US EPA ID Number rState TrgRgrter s#Q Reserved <br /> 77 <br /> J F Tcanp9}SeS Phone A — <br /> J <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number7-1 <br /> r -y^tote (Itfjes1D� - - <br /> ..; Vim, <br /> 12. Containers 13. Total IA. Unit v " <br /> 11_ US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number} No Tye Quantity Wt/Val L. 1('r"gsTe.Num'6er <br /> z iIASTK.FLAIl1lAHLS LIQUIDS, R,O.S.(GASOLIXE, DIRSBL), 3 i1A1933 PGII Stgte 213�`r� <br /> RQ {D018) UG#(128) ol 1 0101 f T T G EP Otfter bdIU1 <br /> 11 <br /> E state n ._ <br /> o N <br /> E IAIOth %' <br /> R <br /> A c State f s <br /> a T <br /> co 0 CpA/C31f er <br /> R r <br /> ur .FSA/F)fher <br /> U <br /> I <br /> Q f <br /> O 15_ Special Handling Instructions and Additional Information s � Q 1--w,1 <br /> -+ CP <br /> 9MCKNCi 21SPONS6 CALL (800) 447-7701 Ulf <br /> t�� •- / <br /> F <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,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I°m a large quantiy generaiar,I certify that I have a pro <br /> grarn in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that f Irava selected the practicable method aF treatment,"storage,or disposal currently available to me which minimizes the preseui and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,I have made 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----- -- - Signature r� MoF�-1 <br /> Day Year <br /> Z rte .-_c"/;�c �f 1 ) 2 <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> f R <br /> A Print d/Typed Name Signature Month Day Year <br /> nl <br /> P <br /> U- 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> E <br /> Q <br /> 19- Discrepancy Indication Space T 1' -_ .iy L('1�t' � rl..�1��.,E},@� �Ls` <br /> z A � li^ t s-L'1 Y�Y t 117 N tY+tYf fit` S vtL <br /> C JA Y�o-i ko <br /> I .fie ` ,�, t, -t mac,- .►,J A`1 1 ft oz <br /> � i � 0 <br /> 1 20. facili ner or Operator Certificot' n of receipt of hazardous materials covered b this manifest exc t as noted- 9. <br /> T Frinted ed Nome Signature th Day Year <br /> rY - 1 <br /> . <br /> - p DO NOT WRITE BELOW THIS LIN <br /> SC 8022A[7/991 White: TSDF SENDS.THIS COPY TO DISC WITHIN 30 DAYS, <br /> A 87022A To, P C)- Box 3000, Sacramento, CA 95812 <br />