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State of Californio—Environmental Protection Agency <br /> FornTApp4pyb4OMB No.2050-0039(Expires 9-30.94) See Instructions on back of -`'fie 6. Department of Toxic Substances Control <br /> Please "ntnr'ype. Form designed for use on elite 12 itch er. Sacramento,California <br /> .a pn ip 9 ( 'P )�'. <br /> 1. enerator's US EPA ID No. Manifest Document No: 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST n " ( i - Q{ 1 ( is required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Address A.State Manifest Document Number <br /> 93110 <br /> n 21 '0DII Cr1-- 9512-11 B. State Generator's ID t- �f g A <br /> C14 <br /> 4. Generator's Phone (�()D) ['� ij A 2 G 4 i <br /> O 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID 400$s`" <br /> O <br /> , '1 y i D. Transporter's Phone <br /> (916) 372-2342 <br /> Q7. Transporter 2 Company Name 8. US EPA ID Number E, State Transporter's 1D <br /> U F, Transporter's Phone <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID x <br /> 0 ✓+•._ . <br /> I C1 Al T1 06 10 10 1 11 110 151.9 <br /> LL j 2 at`+� �� H. Facility's Phone <br /> 3l q 01 0 7 1 31 t ) 595-6597 <br /> U 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shippin Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol 1..Waste Number <br /> a. �:�1 . �' S ►�S state 33 <br /> E . JJ - <br /> oo N b. &1(,, 1(' 5 `3 i <br /> E <br /> A S t <br /> O State <br /> 00 TO C. DSS <br /> R EPA/Other <br /> H d State <br /> Z <br /> w <br /> U EPA/Other <br /> LU <br /> Z J. Additional DescriptkM576T-1GC a s lis A ve ancling Codes for Wastes Listed Above- <br /> 0 <br /> bove- <br /> CL <br /> UJI <br /> d. <br /> J <br /> 0 15. Special Handling Instructions and Additional Information <br /> H <br /> Q <br /> Z <br /> _ 24'L? -3—LL, (209)369-4-663 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> J packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> Q <br /> U <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 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 /> d threat to human health 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 <br /> N -- <br /> waste management method that is available to me and that I can afford. _ <br /> d <br /> Printed Name/. SignaturrJee �.i. Month Day Years <br /> U <br /> ZI.i T 17. Trans rtes 1 Acknowledgement of Receipt of Materials <br /> R <br /> L <br /> A Printed/.Typed Name Signature <br /> llJ P <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials I <br /> w R ✓�� Month DayYear <br /> LL e Printed/Typed Name I ignaturr % ' �.. <br /> 0 R 9 �-_� // S <br /> /i ,. <br /> w 19. Discrepancy Inditation Spoce <br /> N <br /> Q F <br /> U A <br /> Z C <br /> 1 <br /> L <br /> 1 20. Facili Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted ip Item 1 <br /> T Printed/Typed Name f -^ Signature �� f/,�+'� Month Day Year <br /> y -Jam' '! C G G+ �. �7; T" <br /> DO NOT WRITE BELOW THIS LINE. <br /> fellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC -thin 30 days <br />