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.�'. .' ... .. ytanva .tw■Iffj`9erv(osa <br /> U•o1,calif= atth enc We re A9en , i { oxW9ubslances., rol.D1418 <br /> Form proved OMB o" ' 9'(Ezpkes� 1BaaameMoh'"Gglomla <br /> a>Please. rinl or type'�.i(Fom1 daebdruss Ne( -p ewrHed Ali1. Generator's US EPA 10 '-.Manliest !2'`Psge 1 "`,.r- <br /> UNIFURM HAZARDOUS'" hnforme0oein ihe'Shaded areas' <br /> xument Na <br /> = WASTE MANIFEST% l' '. .of/ Isnot required by Federal Inw — <br /> T.Generator's Name and Mailing Address - - /JG ���� f A State Menlieet Document Number <br /> 6075 <br /> .A'%fr�C 6vf3 4r es2 �wG <br /> _C4 , B �Stete Generator's ID <br /> �j� <br /> t ` $. Generator's Phone QQ�) -S Z - <br /> S. Transporter 1 Company Name 8: US EPA ID Number C. State Transporter'$ID <br /> a) <br /> D. Transporter-.*Phone <br /> m7. ransporter.2 Company Name -a. US EPA ID Number E. State Transporter's ID - - <br /> g ,. F. Transporter's Phone <br /> m 9. Designated Facility Name and Site Address 10. US EPA ID Numbbr' G. State-Facility's ID" <br /> t <br /> H. Facility's Phone <br /> 3G/(O. <br /> U 49Ad <br /> Z12 Contamern 13. Total f$. I. <br /> ¢ , <br /> 1/..US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) Quantity 'Unit Waste No.4 _ <br /> No. -Type Wt/Vol <br /> {A2'' sta,ed/ <br /> Z O a( y�/IUC�i9 I��P /•tom ©�I� EPA/Other <br /> E <br /> N State <br /> A /IECrV ��'lP.� D� - EPA/Other - <br /> vq, c - i:. , • State y,= -: <br /> g MAILED. . A/Other <br /> ¢ - State <br /> d. <br /> u~Zi _ EPA Other <br /> all d Aeditbnel;0esutptlonafor Materials Listed Abava <br /> ZO <br /> 01 <br /> 16. Special Handling Instructions Additional��v//J/ �F (c�.v��l• �•Silf%�i/�i c^/i14/Z� <br /> � O,y�c ifi/�llt.S�•c�l?3" i6 !-firl/.�,d:<•�• . <br /> J <br /> J <br /> tl 18. . <br /> GENERATOR'S CERTIFICATION: I hereby declaren that the contents of Mle consignment are July and by highway <br /> y described above pl proper shipping name <br /> ' and are claaaifletl,packed marked,end labeled,end aro in all respects in proper condition far tranapon M Mphway epccrcing to applicable International and <br /> d national government regulations. - <br /> m <br /> ¢ If t em a large quantity generator.I ceniry that I have a program In place to reduce the volume end toxicity of waste generated to the degree I have nimize rose <br /> O to be economically practicable and that I have selected the practicable method of treatment;storage,or diaposal currently available to me whits mlY Wast the <br /> } present and future threat to human health and the environment:OR.if I am a small quantity generator.I have made a good faith elfin to.minimize my weals <br /> U 9enention and select the beat wsets management method that is&"liable to me and that 1 can afford. <br /> WW9 Printed/Typed Name Signature Monfh Day Year <br /> ¢. <br /> W <br /> W T 17. Transporter I Acknowledgement of Receipt of Materials ' <br /> R '9neture Month Day Year <br /> a <br /> Z A Printed/Typed Name - - <br /> //_ !— <br /> P 18. Transporter 2 Acknow gement of Receipt of Matedala <br /> UR PtlMad/Typed Nauta 'Slgnetura - Monts Day Year <br /> E <br /> Z R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> -C <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materiels covered by this manifest except as noted in gem 19. <br /> TSignature Monts Day Year <br /> y Printed/Typed Name <br /> ,0u r'\ 0"t—\-) I/ o� 1 <br /> DHS 8022 A(I188) Do Not Write Below This Line <br /> EPA 8700-22 -----� <br /> (Rev.9-a8)Previous editions are obsolete. r <br /> 1 Ci-Yellow:TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br />