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btate of Lalitornto—tnvironmental rrotection Agency <br /> Form Approved OMB No 2050-0039{Expires 9 30 99) See Instructions on back of page h Department of Toxic Substances Control <br />' Please print or type Form des+gned for Use on elite(12 pitch)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 /> WASTE MANIFEST } {� f� � � is not required by Federal low <br /> 3 Generator s Name and Mailing AddressV.r i+�La„�l[,� ��{ A State Manifest Document Number 21 <br /> p»768 6yw, �y <br /> B State Generators ID <br /> LO <br /> LO 4 Generators Phone {f4 3 2"0 <br />' CV 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> op <br /> D TransporTer's Phon <br /> O � ;ip <br /> CJ .+ <br /> m 7 Transporter Company Name 1� 8 US EPA ID Number 1 E State Transporter s ID[Reserved] ) <br /> F Transporter s Phone r2o (6 <br /> V 9 Deslg[ated Facility Name and Site Address 10 US EPA ID Num6er t f G State Facility$ID <br /> Q !<1sltf l(tBI Ems f�y-: Ler Il d ! t ` <br /> ae <br /> Z1�% jlGlypS. //� g y g r} H Facility E;�P}hone�p ( <br /> l v e f�Gr 1 K LA q -31-1 � � � &} (: U i �'i v (.i � 7 4 cr �^t 1� Cfr4P <br /> 12 Containers 13 Total lit Unit <br /> V11 US DOT Description(including Proper Shipping Name Hazard Class,and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> = <br /> a <br /> /' `, rStateI�If•� [���f Q i7 f71fr�a+Y.dS >ff)��" <br /> (11 L,: EPA/Other <br /> E State <br /> a N00 <br /> b <br /> m E EPA/Other <br /> v R <br /> A c State <br />' C> T <br /> mO EPA/Other <br /> R <br /> lu d Stare <br />' wEPA/Other <br /> V <br /> J Additional Descriptions for Materials listed Above t 1 K Handling Codes for iWestes Listed Above <br /> a ( /� <br /> U11 <br /> w _ <br /> t7 d <br /> � t i t / F• 1 � i i i t + t � t <br /> Q15f ,S(peccial H{a�ndhn/Instruction a/nd Addiho al Information 7�` lt,<wit: �� ''� -717 <br /> H u�1L'" `' 1011 I t1�4 6,.,Ji+s-i1��.r ��� /� ^ �"' ( s✓ <br /> Z At t t o �-t�[ r <br /> _i 16 GENERATOR's CERTIFICATION I herebydeclare that the contents of this consignment are full and accurately described above by proper shipping name and are classified packed <br /> Vmarked,and labeled and are in all respcts in proper condition for transport by highway according to applicable international and national government regulations <br /> 1 <br /> IFI <br /> 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 6e economically <br /> a` practicable and that I have selected the practicable method of treatment,storage or disposal currently available to me which minimizes the present and future)trail to human fiealth <br /> and the environment OR if I am a small quantity generator,I have made a gopd fgith effort to minimize my waste gen9ration and select the best waste management method that is <br /> Oavailable to me and that I can afford {r /f 1� <br /> PrmtediTyped Name /'7 01 UqSignature t � I 1 Montlg Day Year <br /> W T f r Transporter 1 A nowled emeni of Receipt of Materials r" E <br /> sEia N Frinle�/Typed Nci e�3 Signature i / ,7 f ^LU )0 � Ile L Month Day Year <br /> ' { L } <br /> ii p 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 RPrinter ed Nam t Signature l ✓ J • Month Day Year <br /> Q <br /> L) 19 Discrepancy Indication Space <br /> A <br /> Z � <br /> C <br /> I <br /> 1 20 Facile Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> 7 Panted/Typed Name / Signature F" M nth Day Year <br />' DO NOT WRITE BELOW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC 8022A [1/99] {Generators who submit hazurdous waste for transport out of state, <br /> EPA 8700-22 produce completed copy of This copy and send to DTSC within 30 days 1 <br />