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State of California—Environmental Protection Agency <br /> I <br /> Form Approved OMB No 2056-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on else(12 prdch)lypewrder Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Informain the shaded areas <br /> is notion t required by Federal law <br /> WASTE MANIFEST CLA.1,L f1 Iril r)jU a r % ` '7 j of <br />' 3 Generat - r tt ` .:F <br /> J I- ifC"^r tL �'7 1 Cr C / B State Generator s ID <br /> Lo <br />'^ 4 Generator s Phone <br /> (N 5 Transporter I Company Name 6 US EPA ID Number C State Transporter;ID <br /> 00 <br /> 1 D Transporter Phones 5-76_,g <br /> 7 �^� 5 <br /> o JC'�•, ,G c.tv � �c C,� .7. ;�/' � l L+ l) s �~,g ] C� <br /> 7 Transporter 2 Company Name 6 US EPA ID Number E State Transporter s ID <br /> QF Transporters Phone, i - <br /> U 9 Designated Facility Name and Site Adaress 19 US EPA ID Number G State Facility s ID <br /> ' &'r"t o, f ill g <br /> a�4t �flanrr H Poi Phone y 7^ 12 Containers 13 "'Total IA Und <br /> la1 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number} No Type Quantity Wt/Vol I Waste Number? <br /> C"", <br /> �s t <br /> ° /V�h� !'� L;'i r`-�., �,L«�[,t'u_y ;.��v�� �'(�G c,rc-� stale <br /> � EPA/Other 1 <br /> 3i G <br /> 04 E b Slater <br /> CID N <br /> as E EPA/Other If-1, <br /> t <br /> v R <br /> IN <br /> t.s <br /> A c State_ <br />'O T s r Y <br /> W G EPA/Other <br /> R <br />'tau d State r ', <br /> Z <br /> Wf <br /> V EPA/Other <br /> W <br /> J c Addshonof Descrtpttona Fvr Materials Listed Abo�vo's. t v 4 c', A- K Handling Codes For Wastes itsled Above' <br /> 4� #s=s r w �-�.rrr;,�^, _�+ t d �.•". .:,. ~�.z <br /> r � i� � '� s r i s .. i i e Y r 1 a } , �s•� ` pp}, � �.,r M a a� <br /> 0. f <br /> 4 <br /> w {.-. d s <1'• <br /> �Q r�.�ym.K':e'.k`r; �ffz t Gr e.r w1.,i 4 +,. Kt _ f t sr ✓ s �ss,>• 5�r "uy .fy sw,,, <br /> /. ;."f Mk +<„f i}714 V4 f a <br /> ]r <br />�O 15 Special Han&ngInstructions and Additional information r /up /f�•:�y�/ /-f��rl r {y4 <br /> Z 5�:}clLn <br /> W <br /> tir rte! <br /> .tea 16 GENERATO CERTIFI ATION I hereby declare thot the contents of thss consignment are fully and accurolefy described above by proper shipping name and are classified packed <br /> arked <br /> Q mand labeled and are in all respects in proper condition for transport by highway according to applicable mternationaf and notionol government regulations <br /> V <br /> -� If I am o large quantity generator I certify that 1 have a program m place to reduce the volume and toxicity of waste generated to the degree I have determined l0 be economically <br /> n practicable and that I hove 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 ennranment OR of I am a small quantity generator I have made a goad faith effort to minimize my waste generation and select the best waste management method that is <br /> ¢ available to me and that I can afford <br /> O <br />'} Printed/Typed Name � I � Signature � !' '� r Month Day Year <br /> Z t q <br /> W T 17 Trans ort r 1 Ac ow{ed <br /> naemet/af nt of Recit Materials <br /> C4A <br /> � p Printed/Typed Name JJII f/(I Signature � Momh _ Day Year <br /> W P 1 I r� "1C I j g / <br /> 0 18 Trans Drier 2 Acknos4edoement of Receipt of Materials t <br /> 0 R Printed/Typed Name Signature Month Day Year <br /> T7 <br /> � E <br /> Q R <br />'V19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 26 Fouh Owner or D razor Certification of receipt of hazardous materials covered by this manifest except ps noted in Item 19 <br /> Printed/Typed Nom F Signature /} Month Day Yepr <br /> 40— <br /> LA11V�___ <br /> DO NOT WRITE BE OW THIS LINE <br /> DTSC 8022A (41971 ^n- r v sut) 2_- C e e 1'c c �a <br /> EPA 8700-22 <br />