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<br />Form ApPraved Oi.W No. (L-xpirs& 6-30-9 1)
<br />ToxicSubstancesControl Division
<br />Sacramento, California
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<br />N s�_— & r; Generators U`3 EPA 10 Flo. Manifest 2. Page 1 Information in the shaded areas
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<br />VASTE MANiFEST I I I rs of is not required by Federal law.
<br />A. State Me�iles' E]ocumant Num'71#t
<br />Generator's Name end Mailing Addrasa �. a�
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<br />6. Transporter T CompanyName 8. US EPA 11 Numher C Si (e iters rterstP; '" 4 • {" r �"' '
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<br />7_ Z nrpdrter 2 Company Name &' US EPA 10 Number E SSt9 6Tana Bt BiO. a t`"
<br />9 Designated Facility Name and Site Address 10. US EPA ID Numbor
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<br />15. Special Handling Inatructtorts ai*.d Additional Information
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<br />16.
<br />GENERATOR'S CERTSFICAVON: I hereby declare that the contents oft" consignment are fully and accurately described above by proper ahippinq name
<br />and are classified, packed, marked, and labeled, and are in all respects in Impar condition for transoorl by highway according to applicable intemefional and
<br />national government regulations.
<br />if I am a large quantity generator, f certify that I have a program In place to raduce the volume and toxicity of waste generated to the degree I have determined
<br />to be emdnomlcally practicable and that I have selected the practicable mdlhod of treatment, storage, or disposal clsrrsrNfy eva{l6ble to me which minimizes the
<br />present and future threat to human health and the environment; OR, If I am`k small quantity generator, I have meds it good faith effort to minimize my waste
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<br />generation and select the beat waste management method that to avalme and that I ran afford.
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<br />Printed/Typed NameSigrltitura Month Day Year
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<br />17.•Tre aportet 1 Ac now sdgement of Receipt of Materials M• - _ __. ._ , _.: .
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<br />Printed/Typed Name
<br />SignAure _. .,. .._-__ Month Day Year
<br />18. Tren porter 2 Acknowledgement of Receipt of Matede!s
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<br />19. Discrepancy Indkatlon Space
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<br />. acuity owner or Operator Vertification of receipt of hazardous materials motored by this manifest except as doted In Item .19_-
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<br />Printed l Typed. Name �. _ , ... ... - ..... _..
<br />Sigealure - ---.. _ _ Month DRY. _Year
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<br />4S 6022 A (1 r58) Do Not Writi Below This tine
<br />°A 6100-22
<br />er. 9-86)prefioua editions are obsolete.
<br />' Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS
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