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:,tale or Lailtornio—rrivtronmental Protection Agency <br /> Form Approved OM6No.2054-0039(Expires 9.30.99) See Instructions on back of page 6. Department of Toxic Substances Coni <br /> Please print or type. form designed for use on&file(12•pitchl typewriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> s not required by Federal law. <br /> WASTE MANIFEST A 1, F' 0 'D 1 2 ? 1 C' of 1 <br /> ding Address A. Stall Manifest Document Number 21424552 <br /> o BRRI_HAM r'IT'rr 1.rr 24302 B. eroseGeneratorsID <br /> u7 <br /> in A. Generator's Phone (i5i O G ) °^1-t C•l'� <br /> t\ <br /> N S. Transporter 1 Company Name 6. US EPA ID Number C. Stott Transporter's ID Rese d.] <br /> h <br /> O ?H1:,r HA7,APX)4 3,:(sj,1'^Z��rfi4 _ h 13 1) �t vs 4 �,� 9 •'e � D. Transporter's Phone <br /> O <br /> 00 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Transporter's ID[Reserved.) <br /> JJ F. Transporter's Phone <br /> J <br /> Q <br /> 3 V 9. Designated Facili Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Q Q <br /> CR 3 t; K1 R;� <br /> 41 f ! v <br /> Z jf'f) W 77TH :T � � t�A ZB (,�r,9 �/9 H. Facility's Phone %7,�4jl32-STj+�I <br /> .l O L'-,-VG SEACHr - - C3.= z— <br /> T LL <br /> J 12. Containers 13. Total 14. Unit <br /> 1 V 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) No T e Quantity Wt/Vol I. Waste Number <br /> J Z C-DIE*3E1, c 7LB5Cd;BENT3 stat. 222 <br /> 17�tZ—RCRA Fihyi,RP=?Ll Uel?'?'£ °�L 7.� EPA Other <br /> 3 G 2 p ' G {ion—rare <br /> • E <br /> State <br /> o N b. <br /> CD E EPA/Other <br /> v R <br /> C14 A State . <br /> o T C. <br /> m 0 EPA/Other <br /> R <br /> State <br /> w d. <br /> t- <br /> Z EPA/Other <br /> w <br /> V <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> a. <br /> Is. <br /> CL FR-DrILE #�6Pyf <br /> sA <br /> U.1 c, d. <br /> ac <br /> J <br /> Q <br /> Z 1 c a <br /> � 'H d i�Ins_ ctio s and Additional Infgrmati n <br /> O T' ,W ]�ii:✓QrE t_T i.'d L �'L'yl N°1 CI^, J'�£ .I Irt'F: £LYT_tdG J, 1�r t 1 14. .l hCY.T_R3E Itt, RS FON <br /> Z A5^5L� <br /> w "DMT— GEWY CC11'TACT: i 000 1 795—+4-19~ <br /> IEC E-k_r=. PAGE !1 1171 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and occuratelr�described above by proper shipping name and ore classified,packed, <br /> Vmarked,and labeled,and ors in all respects in proper condition for transport by highway according to opplicable international and notional govemment regulations. <br /> II 1 am 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 /> n practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,I have mode a good faith effort to minimize my waste generation an 'select the best waste management method that is <br /> O av •obit tom and that I can afford. " ^ ^�� <br /> / Signature Month Day Year <br /> Prin d d Na a i S! <br /> w T 17 Transporter 1 Acknowled emelt of Recei i of Materials •' <br /> Printe� typed 1 Signaturee,% J Year <br /> W /'( Nome i i , �,__• v _ i <br /> W S <br /> P <br /> w 0 18. Transporter 2 Acknowled ement of Recei t of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E <br /> to It <br /> Q <br /> V19. Discrepancy Indic ation Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> ' 20. Foc;lity Owner or operator Certificotion of receipt of hazardous materials covered 6y Chia manifest except as noted in Item 19. <br /> J Signature. �; / Mont^ Day Year <br /> tri fmt d/T d Name �l/ 1/�r .✓T '7 <br /> 1 ' DO NOT WRITE BLOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> Green: TRANSPORTER RETAINS <br /> EPA 8700-22 <br />