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J <br />G. State Facility's ID <br />State of <br />Cal 'ifornio—Environmental Protection Agency <br />No. 2050-0039 {Expires 9-30-991 <br />See instructions on back of 6. <br />Form Approved <br />OMS <br />type. Form designed for use on elite (12 -pitch) <br />00r. <br />Please <br />print or <br />1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 <br />o 7(•?S-) S. SCI rn ST. <br />UNIFORM HAZARDOUS <br />I <br />1 S. Trans arler 2 Acknowled ement of Receipt of Materials / <br />WASTE MANIFEST <br />of <br />Printed/Typed Name ! 5i nature <br />Cli 1-) I' <br />A. State Manifest D«vment <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />3. Generator's Name and Mailing Address <br />a. <br />140N-R;--'F.A HAZ ARIDIDUS WASTE L_ I OU I D <br />THE POPT OF STOC:1 70-01 <br />_ <br />: WATE4: Sc SLUDGE) <br />1' - <br />'r•:>:1 Ww WASHINGTON ':33T. <br />`r (• f;Tt•�I1i`I , A •�•,; 03 B. Stole Generator's ID <br />S� O fw 5,'1 <br />o <br />rn <br />A. Generator's Phone 21-1'j <br />E <br />K. Handling Codes for Wastes Listed Above <br />5. Transporter 1 Company Name <br />6. US EPA ID Number C. State Transporter's ID <br />T <br />' IOF: I-:S-�I�L- O 1 L <br />Aft '=.'i Lq_ 4 1 1 a c� D. Transporter's Phone <br />O <br />m <br />7. Transporter 2 Company Nome <br />$. US EPA ID NumberE. State Transporter's ID <br />J <br />G. State Facility's ID <br />V <br />T <br />9. Designated Facility Nome and Site Address 10, US EPA ID Number <br />�-c <br />I <br />II`D HSTF -'IAL. SEFVICIE CSIL CO. <br />W Z <br />12. Containers 13. Total <br />o 7(•?S-) S. SCI rn ST. <br />No. Type Quantity <br />Wt/Val 1. Waste Number <br />1 S. Trans arler 2 Acknowled ement of Receipt of Materials / <br />State_ ,� <br />R <br />T <br />Printed/Typed Name ! 5i nature <br />Cli 1-) I' <br />13 EPA/Other <br />11. US DOT Description (including Proper Shipping Nome, Hazard Class, and ID Number) <br />�yy� <br />Z <br />4C?? <br />a. <br />140N-R;--'F.A HAZ ARIDIDUS WASTE L_ I OU I D <br />Q') 3 <br />� <br />: WATE4: Sc SLUDGE) <br />o <br />F <br />N <br />6' <br />oo <br />E <br />K. Handling Codes for Wastes Listed Above <br />v <br />v <br />R <br />A <br />C <br />ca <br />T <br />O <br />R <br />Ce <br />d. <br />1-- <br />Z <br />LUV <br />Lu <br />V) <br />I <br />J. Additional Descriptions for Materials Listed Above <br />Z <br />oTANK' <br />BOTTOM WASTE <br />LU <br />R I NSATE <br />J <br />Q <br />DeparlmonF oxic Substances CantrOl <br />Sacramento, California <br />Information in the shaded areas <br />is not required by Federal law. <br />98801-686 <br />F. Transporter's Phone <br />G. State Facility's ID <br />w <br />T <br />17. Trons otter I Acknowled ement of Receipt of Materials <br />H. Facility's Phone <br />I <br />Printed/Typed Name Signature <br />LU <br />tLU <br />12. Containers 13. Total <br />14. Unit <br />No. Type Quantity <br />Wt/Val 1. Waste Number <br />1 S. Trans arler 2 Acknowled ement of Receipt of Materials / <br />State_ ,� <br />R <br />T <br />Printed/Typed Name ! 5i nature <br />Cli 1-) I' <br />13 EPA/Other <br />t <br />Slate <br />EPA/Other <br />- <br />State, <br />-... - <br />EPA/Olhor <br />C <br />I <br />Stole <br />EPA/Other <br />K. Handling Codes for Wastes Listed Above <br />T <br />c, <br />d. <br />Z 15, Special Handling Instructions and Additional Information <br />a ,F•EaG:D�',T: I <br />ATE PRCI7'EI_ T I VE. C LOTH T N <br />Z "Et IEF GE.NC:Y CONTACT- ('2:r--15 -) 541--9141-51' <br />z ,EE �. �:', ta. 171 <br />t— <br />J 16. GENERATOR'S CERTIPICATIGN: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and ore classified, packed, <br />Q marked, and labeled, and are in oil respects in proper condition for transport by highway according to applicable internatianol and natio nal government regulations. <br />U <br />J <br />If 1 am o large quantity generator, I certify that I have a prooram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />© practicable and that I hove selected the practicable method o treatment, storage, ar disposal currently available to me which minimizes the present and future threat to human hea6} <br />p <br />and fhe environment; OR, if I am a smalV quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br />K available to me and that I can afford. <br />Q Month Doy 1 Ye <br />>- Printed/Typed No Signotur /� i I A'0V I <br />this manifest except as noted in Item 19. <br />DO NOT WRITE BELOW PHIS LINE. <br />oath Day ear <br />TOLL <br />Month Day Year <br />Month Day Year <br />Yellow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A (d/97) produce completed copy of this copy and send to DISC within 30 days.) <br />EPA 8700--22 <br />w <br />T <br />17. Trons otter I Acknowled ement of Receipt of Materials <br />�R <br />I <br />Printed/Typed Name Signature <br />LU <br />tLU <br />s <br />.TI F <br />LL <br />P <br />0 <br />1 S. Trans arler 2 Acknowled ement of Receipt of Materials / <br />0 <br />R <br />T <br />Printed/Typed Name ! 5i nature <br />LLJ <br />V) <br />R <br />t <br />U <br />19. Discrepancy Indication Space <br />- <br />F.. <br />A <br />-... - <br />C <br />I <br />L <br />I <br />20- FacilityOwner or Q eralor Certification of recei t Of hazardous materials covered L <br />T <br />Printed/Typed J Signaru .• <br />Y <br />this manifest except as noted in Item 19. <br />DO NOT WRITE BELOW PHIS LINE. <br />oath Day ear <br />TOLL <br />Month Day Year <br />Month Day Year <br />Yellow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A (d/97) produce completed copy of this copy and send to DISC within 30 days.) <br />EPA 8700--22 <br />