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State of Cal ifornia—Envirpnmenial Protection Agency 1V� 9 /, � r/��j,
<br />See Instructions on back of b. Department Sk/loxic Substances Control
<br />Form Ap v-oved OMB No. 2050-0039 {Expires 9-30-991 Sacramento, California
<br />Please, Jmi or type. Form designed for use on elile (12-pilch) filer.
<br />1 G t US EPA ID No Monifest Document No. 2. Page I Information in Ike shaded areas
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<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST I_:
<br />3. Generator's Nome and Mailing Address
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<br />cel 5. Transporter 1 Company Name 6. US EPA Ip Number
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<br />00 7. Transporter 2 Company Name 8, US EPA 1D Number
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<br />9. Designated Facility Name and Site Address 10. US EPA ID Number
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<br />IfNUUIS l F.IAL_ SE1.V1C--.E GI' I_.1=1.
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<br />A, State Manifest Document Number 89.16
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<br />State Generator's ID
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<br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number)
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<br />J. Additional Descriptions for Moleriais Listed Above
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<br />Z15. Special Handling Instructions and Additional Information
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<br />t- PPF.'OPF'IATE F'F'OT-EI_TIVE CiLOTHINI1
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<br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of This can s'
<br />are fully and accurately described above by proper shipping name and are classified, packed,
<br />Q marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
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<br />_ If t pm 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 economically
<br />a practicable and that 1 have selected the practicable method of treatment, storage, or disposal currently available to which minimizes the present and future threat to human health
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<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 hest waste management method that is
<br />Cr-' avoilaMe to me and that I can afford.
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<br />A, State Manifest Document Number 89.16
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<br />12, Containers
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<br />Type
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<br />K. Handling Codes for Wastes
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<br />Z15. Special Handling Instructions and Additional Information
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<br />t- PPF.'OPF'IATE F'F'OT-EI_TIVE CiLOTHINI1
<br />Z "EMEF:CiE aC:Y CONTACT. (209')541—'--!145"
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<br />EE E. F'.1j. 171
<br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of This can s'
<br />are fully and accurately described above by proper shipping name and are classified, packed,
<br />Q marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
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<br />_ If t pm 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 economically
<br />a practicable and that 1 have selected the practicable method of treatment, storage, or disposal currently available to which minimizes the present and future threat to human health
<br />to p
<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 hest waste management method that is
<br />Cr-' avoilaMe to me and that I can afford.
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<br />DT5C 8022A (4/971
<br />EPA 6700-22
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<br />Signature ,�onth Day ear
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<br />%•Si ature Month Day Year
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<br />,us materials covered 6y -this manifest except os noted in Item 19.
<br />Signature .% Month Day Year
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<br />DO NOT RITE BELOW HIS LINE.
<br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.
<br />(Generators who submit hazardous waste for transport out-of-state,
<br />produce completed copy of this copy and send to DISC within 30 days.)
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