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Slate of California—Health and Welfare Agency ` T • `Department of Health Servicr <br />Form Approved OMB No. 2050-0039 (Expires 9-9) v Toxic Substances Control Divisir <br />Please mint or tvoe. !Form daaionad for use nn .1n. ff..eanh r.........ae.l e.....____ _.._-_ <br />-11 auzz n tl/ea) Do Not Write Below This Line r <br />'A 8700-22 <br />.v. 9-88) Previous editions are obsolete. <br />Yellow: TSDF SENDS THIS COPY TO (Ir',!ERATOR WITHIt <br />UNIFORM HAZARDOUS <br />1. Generator'- US EPA ID No. Manifest <br />3 <br />2. Pepe 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />Document No. <br />of <br />Is not required by Federal law. <br />3. Generator's Name and Meiling Address ///s <br />4wl Tcf.s Sys EU;1 <br />A. State Manifest Document Number <br />/�,,( 's t- - <br />�T 4X.1.(' / <br />B. Stare Generator'sj852,7739 <br />4. Generator's Phone (ryi. ) T c� G <br />31t3_ Cej <br />5. 4spo er,t mp Name 8. US EPA ID Number <br />C. State Trenaportsr'a ID L/ <br />/J—�( _tom 617is-11 t-.)rr <br />D. Transpor er's Phone <br />J, <br />T. Transporter 2 Coany Name 8. US EPA ID Number <br />E. State Transporter's ID <br />� <br />F. Tranaporter's Phone <br />9/,J�0,eeignated Facility Name and Site Address `10. _C U/S/EPA INumber <br />)lrrrrrAn1f t+� ' •� �� �LTN K//I <br />O. State Facility's ID <br />I <br />H. Facility's Phons <br />-3 7 70 <br />11. US DOT Description (Including Proper Shipping Name, Hazard Claes, and ID Number) <br />12. Containeilat <br />13. Total <br />Quantity <br />14. <br />Unit <br />1. <br />Waste No. <br />i <br />Na. Type <br />Wt/Vol <br />a. ( <br />���:b� y�! �ai/7Gy�ru'L <br />` <br />Stele <br />G <br />Lr/ <br />EPA/ er <br />E7.� <br />N <br />I <br />E <br />R <br />b. <br />State <br />A <br />T <br />EPA/Other <br />0 <br />R <br />C. <br />State <br />EPA/Other <br />d. <br />Slate <br />EPA/Other <br />J. Additional Descriptions for Materiels Listed Above ' <br />K. Handling Codes for <br />Wastes Listed Above <br />rr,��, +RI�$4 <br />a. <br />b. <br />-Goy I <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />18. <br />GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br />and are classified, packed, marked, and labeled, and are in all respects In proper condition for transport by highway according to applicable international and <br />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 <br />to be economically practicable end that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the <br />present and future threat to human health and the environment; OR, II I am a smell quantity generator, I have made a good faith effort to minimize my waste <br />generation and select the best waste management method that Is available to me and that I can afford. <br />Printed/ Typed Name <br />Signature Month Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materiels <br />R <br />A <br />N <br />Printetl/ Nem. <br />Signature Month Day Year <br />0 <br />18. Transporter 2 Acknowlledgemen( of Receipt of Materiels <br />RPrinted/T <br />T <br />YP ed Name <br />Signature Month Day Year <br />E <br />19. Discrepancy Indication Space .. <br />F <br />A <br />C <br />r <br />L <br />T20. <br />Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as gots in Ran 19 <br />y <br />Printed/Typed Ne� t <br />/ <br />Signature / Monfh Day Year <br />jQ <br />-11 auzz n tl/ea) Do Not Write Below This Line r <br />'A 8700-22 <br />.v. 9-88) Previous editions are obsolete. <br />Yellow: TSDF SENDS THIS COPY TO (Ir',!ERATOR WITHIt <br />