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State of Call fornia—Env.ronmentoI Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Co-ra <br /> Please Prim,or type roan aesTned for use on elite f 12 p,tcnf typewriter Sacramento Colifornsa <br /> I UNIFORM HAZARDOUS 1 Generator s VS EPA ID No Monitest Document No 2 Page 1 Informouon in the shaded areas I <br /> e is not required by Feaeral low <br /> WASTE MANIFEST �' t £ Ir { r 1 �'/ I' 17 1 ) of <br /> 3 /Genercror s Name and Mailing Address oia�Aanafe0 Ci6 irme4 Ube <br /> 34 <br /> I i f sstr( BSsantr�1 '§fps <br /> 4 Generators Phone �'y <br /> C`! 5 Transaorte Company Name 6 US EoA ID Numoer C",S fait Tr ',IDiRes&'Cr W rWN f 1T <br /> Ln <br /> W I I IJ yfp�er tp - k" <br /> { 1 5 I rf 5 � rl7� of 11 L f �C �� r ^w• <br /> m 7 7ransoorte 2 Comocny Ncme 8 US EPA ID Number _'$f�T r[f 4 fD;late%e�_iveC a `r <br /> 9 Designotec Facdiry Nome and Sire Address 10 US EPA ID Num6er C`iwS�aFer tl f s '�r <br /> ` f iiFav Uv n"O,a ac s T&N <br /> 12 Containers 13 Total 14 Unit _ , 94 <br /> 11 US DOT Des-iption(including proper Shippers Name Hazard Class and ID Numoer) Na Toe Quantify Wt/Vol a �? '' <br /> nV In <br /> I! r <br />' o N <br /> mw E <br /> � R <br /> cv <br /> o T <br />' m O <br /> R 1 , <br /> ui d <br />' Z _I <br /> Z <br /> V � � <br /> t rs.s <br /> `� /�'s o'rf tfe"-'t f`nr; lee eft ti <br /> w <br /> O15 Special Handling lnsrru/ctions and Additional Information ..J- Y{�/ �r 1 r "�flrtj L sly,"+rsr r µJ)1, <br /> Q �It � `s C `l� t r Jr C L' r /'"r�.s � e 3 f� ii r rf�l's"� r l/ •r N[s R (,f�f 1 r �{I !%�1� r� T • } <br /> slAr 7�iL ~{ Lj �- ,1sy <br /> LU <br />' 16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of this consignment ore fully and accurately described above by proper ship mg name and are classified packed <br /> Q monied and labeled and ore in all respects,n proper condition for transport by highway according to applicable international and not onaPgovernment regulations <br /> V <br /> J <br />' If 1 am a large quashy generator I certify that I hove a progtom m place to reduce she volume and tox,uty of waste generated to the degree 1 have determined to be sconamica y <br /> a practicable and that I have Sete-led the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> sir <br /> and the environment OR if I pm a small quantify generator I have made o goad Faith efto rt to minimae my waste generation and select tine best waste management matlriod that is <br /> = available to me and tnat I can afford <br /> OPrinied/Typed Name ( Signature Month Day Year <br /> T <br /> �r B ,7`Tronsoorter 1 Acxnawiedaement of Receipt of Materials <br /> a A Pr,rsted/Tyaed Nome Signature Manth Day Yeor <br /> r �f <br /> 1 P I <br /> st_ 0 l8 Transooner 2 Acknowledgement of Rece,pr of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> N E I <br /> Q R <br />' V 19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> 20 F.'I,ry 0-mer ODeraior Cemtjcorion or recnat of nczordous materials covered by this monites exceot os notes in Item 19 <br /> T P inieci Tvocd ;ane i l Signature Month Day 1 Year <br /> Y A I �1c'3 k / C <br /> DO NOT WRITE BELOW THIS LINE <br /> DTS_- EG:2, ( i sol Green TRANSPORTER RETAINS <br /> EP.. 171Ic—:: <br /> 1 <br /> d' <br />