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Slate of <br /> I-E$Lf*nmV4QI Protection Agency <br /> Appm—A&"Wj".�20"' q(Expires 9-30-96) See Instructions on back of page 6. <br /> 0--print or�t,Q;-d for use an sills(12.p;kh) r Deportment of Toxic Substance <br /> ,a,,troj <br /> Nr t r, Socrarnwoo,California <br /> UNIFORMW WASTE MANIFESTS <br /> HAZAkDOUS 1. Generators US EPA ID No. Manifest Document No. 2� PageI Information in the shaded areas <br /> -7 !4 is not required by Federal law, li <br /> 0 M <br /> jrj of <br /> Me is <br /> Address <br /> Ln <br /> EOX 5 0 4 <br /> j <br /> C4 <br /> in 4. CA �45� <br /> s None E. <br /> 00 <br /> S.�TfOn�".rter I Company Name 6. US EPA I D Number <br /> C, <br /> 7. Transporter 2 Company Name B. US EPA ID Number <br /> U <br /> 9. Designated Facility No"and Site Address 10, US EPA ID Number <br /> 0 <br /> '14" :,,I <br /> Z I1. US DOT Description{including Proper Shipping Name, Hazard Class,and ID Number} 12. Containers 13 Total 14 Un it <br /> No. Type Quantity Wt/Vol <br /> Q. <br /> C4 E <br /> 0 <br /> co N b. <br /> co <br /> 4 E <br /> C4 <br /> A <br /> Go T c <br /> 0 <br /> rr R EPAJOIItar <br /> LU <br /> Z dr <br /> Uj <br /> LLA <br /> Z <br /> 0 <br /> �Z' s kap <br /> LU <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> KeeT. -x^-v frc" scui-ces r,A i.qrdtic-n. Alw �r- �,;ca-r harctiats -,hc�n arr,,vn-1 <br /> Z - - <br /> Uj 'J.G.S.T1. s Narlxe-,e�tf,±-!;�# ro?S phrne <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, I <br /> < pocked,marked,and labeled,and are in all respects in proper condition for transport by highway occording to applicable international and national government regulations. <br /> If I am a large quo" 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 <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currer6y available to me which minimizes the present and future <br /> threat to human health and the environment;OR, 9 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste T2nc!9emenf method at is available to me and that I fon,offord. <br /> 0 Prinild/T <br /> 4- ffet TT #V4f1Pigncrtu,e Mon* Day Year <br /> j 'e <br /> Z T 17. Transporter I Acknowle�dgemenf of Receipt of Materials <br /> LU I — <br /> Printed/Typed NameMorah Dory —Year <br /> w2)4-41 Tt- (2)a' C�" <br /> LU 0 18. T 2 Ackqpwli" ement of Receipt of Materials <br /> I <br /> LA- T Printed/Typed Name Signature Month Day Year <br /> Ljj <br /> V) 19. Discrepancy Indication Space <br /> -cc <br /> F <br /> A <br /> Z C <br /> 0. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> -rinted/Typed Name Signa re Month Day Year Ir <br /> DO NOT WRITE BELOW THIS LINE. <br /> utile TSDF SENDS -'h COPY TO GENERATOR %Vj.-ijN :;C, <br /> su-'-MO ha:c'nou! -aste fo, t'a-�PD- C't-' <br /> DISC 8022A (1/9.5) <br /> EPA 0700--22 <br />