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State of California—Environmental Protection Agency <br /> Fo+m Apnroved OMS No.2050-0039(Expires9-30-99) mb.See Instructions oil back of 6, <br /> Pleat. p....i or type: Form designed For use on elite(12•pitchl gyp Department of Toxic Substances Control <br /> Sacramento,California <br /> UNIFORM HAZARDOUS 1 Ge erotors US EPA o, Manifest Document No. 2. Page 1 Information in the shaded oreat <br /> WASTE MANIFEST ! !1 /i 10101 <br /> 1 I J -3 is not required by Federal law. <br /> i- t LJ of <br /> 3. Generators Name and Moiling Address <br /> --;f Js=Ir` r11;'•r :�`-{ f Ifs l �? y`1 1 G A State Manifest Document Number '{_ i . <br /> wT T1_"I -, s 891636 <br /> rj Y Nr t•.,�' <br /> B. State Generators ID -jk"z f <br /> A. Generator's Phone <br /> LO nt 5. Transporter 1 Company Name 6. US EPA ID Number C Slate Transporter's JD %a s <br /> i,.f-a.L.. 5Ti - 1'1 .� �.a 1-� <br /> © - D Transporters Phone > <br /> O s 20� �iC✓7�r-E?Er92 <br /> 7. Transporter 2 Company Name <br /> 8. U$EPA li]Nvmber E State Tronsporter.s ID <br /> UF Transporters Phone Jnr. }c{ prJ <br /> +� 9. Designated Faluli�y Name and Site Address 10, US EPA ID Number G State Facility's ID tra <br /> Q 11.1E t t TF, ' <br /> � . � H. cility's Pho V' J' p <br /> Q <br /> 11. US DOd Description(including Proper Shipping Nome,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> V P' ( g P pp' g <br /> Z p� No. Type Ouantiry Wt/Vol 1-Waste Number, <br /> 2 J '!—, '[' "4 1-41^,-i+l—'F0JDIJZ_ <br /> . <br /> 73 Ca 1•:fi } Gi'J �i_�,„�L'I�,.._.t ;-, -,t -r 'T t� -' <br /> EAA/Orher <br /> ab. <br /> 0 f State s <br /> 14 A EPA/Other <br /> o T c, <br /> co O Stats <br /> ac <br /> EPA/Other <br /> w d. _ <br /> Z State. <br /> W <br /> V <br /> LU <br /> EPA/Other <br /> ul J. Addilional Descriprions for Materials Listed Above <br /> K. Handling Codes for Wastes Listed Above <br /> TAt4f: a.t �� 6: <br /> LU <br /> Q d <br /> Q15. Special HandJing Instructions and Additional Information r} <br /> �:F•''�.'fr.'E:�C•:,' t.< ri• )•^•t�Ts=1:"�"T t '� !_'1 t_t'?'i•-I.R t`II� <br /> Z EN r. rat,Y <br /> t- <br /> 16. GENERATOR'S CERTIFICATION: !hereby declare that the contents of this consignment are fully and accurately described obove by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and ore in all respects in proper condition for transport by hi <br /> ghwoy according to applicable international and notianal government regulations. <br /> V <br /> ' If I am a iorge quantity generator,I certify that i have a progrom in place to reduce the volume and toxicity of waste generated to Ike degree I hove determined to be economicollr <br /> U] procticabfe and that I have selected the rractimble method of treatment,storage,or disposal currently available to me which minimizes the present and Futuro threat to human health <br /> and the environment;OR, if I am c smolt quanlity. generator, I have made a good Faith effort to minimize my waste generation and select the best waste management method that is <br /> 0 available to me and that I con offord, <br /> y Printed/Typed Name re Si natu <br /> Z 7r', l..._.. Signature ! Month Day Year <br /> LU <br /> V R i 7. Trans oiler 1 Acknawled ement of Recei t of Materials <br /> ti A Printed/Typed Name i <br /> Signature <br /> T f,% f ry Month Day _Year <br /> 0 18. Trons orler 2 Acknawled ement of Receipt of Moterials t ' <br /> T Printed/Typed Nome Signature <br /> Uj <br /> V) 8 Month Day Year <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> t <br /> J 20. Faciii Owner or Operator Certification of receiat of hazardous materials covere is man, st a ce t as noted in)rem 19. <br /> punted/Typed`Name 4 \ 1 Signasu + =M-whoyYear <br /> if , e r <br /> DO NOT WRITE BELOW T�IIS LINE. y <br /> DTSC 8022A (4/971 / <br /> EPA 8700-22 <br />