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. n.. } \ � z ._�DDQ y►1 l/k/. .^ �S "' ""Dart encof Hentr gar Icon <br /> -Fprm 7 ^[^ 19 In o]r--J �J L .,?:,3 0� / •-w' Toxic Substances Control Division <br /> Please cont or type (Fz m designed for use on efiff pifcn fy,a eots,) Sactamentu Califomie <br /> 1. Generator's US EPA ID No. Manifest Pa I - `d <br /> UNIFORM HAZARDOUS Document No. of 13 not required <br /> a the Federal <br /> areas <br /> WASTE MANIFEST not reyulrf`d by Federal law. <br /> 3'Generator' Nal and Ms ling Address A State Man Document Nienoat <br /> [�./C(.t-p,- [J R//State Gens z r s ID ,/� + <br /> n X90:':al or 5 <br /> From,( ) '.S / - 0 1 i./ 'J.�'( V a <br /> rrry� orrtx.1 'om n Nam 1r <br /> - � ! l�! `� � y � ih 8. � NEPA.D Number .C..State.T(ansporter 9� _ <br /> (�' �` L'I ,/'I �I / ,( ,�.� D Transporter z Phon �' <br /> Trnnspn .r? ^r .o:my Name S. US.EPA t.,"Number E. State Transporter' ID <br /> /-1 Ile, IC)iq Ae _F. Trsrepm-I1Ws Plan <br /> in e a <br /> ( '..oretei ecl'nv Neple and Saa Address �y 10. US EPA ID Number G. State Facility's 1D%— <br /> A <br /> d M. ecillty's Phone <br /> - 12. Contei rs 13. Total 14 I. <br /> 1>DOT 0,scripbon(Including Proper Shipping Name,Hazard Class, and ID Number) Quaid Unit Waste No. <br /> i Type Wt/Vo <br /> i. .✓✓c� � f' �.161.S4��Q L(��<f� Slate <br /> EPA <br /> state'+ <br /> _ I EPAt� <br /> rt :: <br /> + EPAy(71Ipr sem:`. <br /> .Additional Descriptions for Materials Listed Above K. Handling Cadeaja <br /> Mid 1RIaI5d�s y< <br /> is <br /> GI � <br /> �. C � �.. ..n.-m. .«,.......� ... •,. ,.....n..+-•MMwa+r.Fl�i ybfia++�Y^`^^aY+SF> ••r-"�-.. ..a ..rowAa...:Y I'. _.. <br /> < <br /> t5 Special Handling Instructions and Additional Information <br /> - I _ <br /> - ; ij t <br /> � GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled. and are in all respects in proper condition for transport by highway according to applicable <br /> I iniern.fionat and national government regulations. <br /> I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated 1Q the degree I have <br /> j ielermined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environment; OR. if I am a small quantity generator,Lhave made a good <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that l can afford. <br /> Signature Month Day Year <br /> 03 <br /> J <br /> g , T 1; iransDorter 1 Acknomdedgefinart of Receipt of Materiels - <br /> y R <br /> Z ! A ?,iniad/Ty ed ame Signature D Month Day Year <br /> < <br /> O O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> Pleded I Typed Name Signature Monts Day Year <br /> CJ E <br /> 19. Discrepancy Indication Space <br /> F <br /> s, <br /> I <br /> 20 Facility Owner or Operator Certification of receipt Of hazardous materials covered by this m81ife8l except as noted in Item 19. <br /> T Pdmed/Typed Name I Signature Month Day Year <br /> Y <br /> DI,S y022 A(1•87) INSTRUCTIONS ON THE BACK <br />