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State G C.M.-io—E.viranreemel Protection Agency <br /> Form Apposed OMS No.2030.0039(Expires 9-30-94) See ID$fFUCfIDO3 OD bOtl b. Departmentof Toxic Substances Control <br /> Mews prim at type. Form designed for use on elite(12p(Ms writer. Sacramento,California <br /> 1. Gemseators US EPA ID No. Manifest Documw <br /> e. �— 2. Page 1 Informatan in Rse shaded gre <br /> UNIFORM HAZARDOUS o required by Fedewl hw. <br /> WASTE MANIFEST La A A 918111415191914141 819 1 719 1 1 of <br /> 3. Generators Name and Mailing Address A. State Manifest Document Nussdser <br /> 9, Santa Fe Railroad 92289179 <br /> 740 Carnegie Road, San Baznadlno, CA 92408-3571 S. State Generator's ID <br /> a Generates,',Ph. (209) 441-2521 <br /> 5. Transporter I Company Name 6. US EPA ID Wnmbar C. State Transporters fD <br /> Erickson, Inc. ICIAIDIO1019141616131912 D. Transporter's Phone <br /> (510)235-13 <br /> 7. Transporter 2 Company Name S. Us EPA ID Flumina, E. State Transporter's ID <br /> a <br /> U ` F. Transporters Phone <br /> a 9. Designated Pacifier,Name and Site,Address 10. US EPA ID Number G. State Facility's ID <br /> do U.S. Ecology <br /> Hwy. 95 12 Miles S. of Beatty H. Facility's Ph.. <br /> Q�a W 8900 INIVIT131310101110101010 70Q2)55 203 <br /> u <br /> 11. I/5 DOT Ascription(ehckrrSrp Prop,ShipP'vip Name,Hazard Clmt,and ID Number) 12. Contairen 13. Total ld. Unit <br /> Z No. T W Wt/Vol 1. Waste Number <br /> State <br /> �3 G a. Non RCRA Hazardous Waste Solid EPA/Other <br /> E 1 D H Nm RCRA <br /> N In. Sime <br /> N R \,j EPA/Other <br /> a A J <br /> T C. ! State <br /> RV EPA/Olher <br /> F — — <br /> Z d, Siena <br /> W A <br /> U <br /> EPA/Other <br /> W <br /> H _ <br /> Z J. Additional Dexripdons for Materials listed Above 16 Handling Codes for Wastes Listed Above <br /> Q <br /> 2 Profile V7- L71 I .r -373 b. <br /> us <br /> W Job '?o i c. a. <br /> 15. Special Handling Inst :flans and Additional Information <br /> Gloves and (goggles 24 Hous Contacts (2041 yr,/- .2 5-/,4 5 FC <br /> Name= C.L. /0ArlCei <br /> W <br /> F F}IO[3a 2O <br /> .�.h 76. GENERATOR'S CERTIFICATION: I hereby declare that the contenhls of fb.coadgnmem oro fully and accurately Itd'above by proper shipping nom.and one classified, <br /> a packed,marked,and labeled,and aro in all respects in proper condition for transport by highway according to applicable federal,store and international laws. <br /> U <br /> If I am o large quantity genermor, I certify that I have a program in place to reduce the wlume and toxicity of waste generated to the degree I haw determined to be <br /> economically practicable and that I have selected the practicable method of treatment,storage, or disposal currently available to me which minimizes the present and future <br /> ythreat to human health and the envirommenp OR, 4 1 am o small quantity generator, t have made a good faith effort to minimize my waste generation and select the beef <br /> ¢' waste mono emem method that is awilable to me and that I can afford. <br /> Q <br /> Printed/Typed Name Signature Momh Day Yew <br /> lJ ' e 4/ . 7'77.'Lt/. / <br /> Z T 17. Tions Her I Acknowfisdigerment of Receipt of Materials <br /> A Primed/T N e Signature 21 <br /> � Month Day Yam <br /> M <br /> G e <br /> 0 16. Treat iter 2 c wled emeht of Raced t o Materiah <br /> W i is <br /> Prvt.d/Typed Name Signature March Day Year <br /> W <br /> O <br /> W 19. Discrepancy Indication Space <br /> N <br /> a F <br /> U p <br /> Z C <br /> 1 <br /> I <br /> I 20. Facility Owner or Opensher Carrificonen of rwai t of hazardous material covered by this manifest sac W as noted in Nem 19. <br /> 7 Prkted/Typed Name Signature M.^ Oar, Year <br /> Y <br /> W 888- 41o63 DO NOT WRITE BELOW THIS LINE. <br /> S Lvfk FE <br /> Blija Po+ Do. 40 SENDS THIS COPY TO DISC WITHIN 30 DAYS.1 <br /> DISC BORA (12/91) To P.O. Boz 400, Sacramento, CA 95812-0400 J <br /> EPA 8700-22 <br />