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'St6 a-of Col+forrsja*—Environmental Prol000mAgency <br /> Form Apprq,ed OMB No 2050-0039[Expires9 30 99) See Instructions on back of page 6 Department of Toxic SubstancerControl <br />' Please pnnl or type Fprm designed for use on thre(12 pitch)typewriter + Sacramento California <br /> 1 Generator s US EPA IQ No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law <br /> • WASTE MANIFEST fr l i�� �! ''� X� {� -7 1 of <br /> 3 Generator s Nome and Mailing Address CY fJ� A State Manifest Document Number l' <br /> 7 <br /> O `�—,S /',1 5 3 J 7 B Stale Generators ID <br /> Lr, ` C♦-7 <br /> Lr) 4 Generators Phone <br /> N <br /> 1 '� <br /> N5 Transporter 1 Company Name 6 US EPA ID Number C Stale Transporter s ID[Reserved I <br /> in <br /> co <br /> O ��f `_ D 7ronsporter s Phon <br /> W 7 Transporter 2 C mpony Name 8 US EPA ID Number E State Tromporter ND[Reserved <br /> t <br /> F Transporter's Phone <br /> V 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s f0 <br /> Q R�vrr b�rL yr J T/uts��r- E: <br /> Z H Foci s Phone <br /> 5'�UU C lu's <br /> �0 18-1 <br /> 12 Co m2ers 13 Total 14 Unit <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) <br /> u p g P PP g No Type Quantity W!/Yol I Waste Number <br /> a C� ! ,.�v p State <br /> = <br /> Al UN U +' tN ;.I L�IiG_y Wt(S-� L!�ir,'G� � , . � ! <br /> EPA/Other <br /> (i � <br /> C14 E b 1 1 State <br /> N <br /> m E EPA/Other <br /> v R <br /> v A c State <br /> o T <br /> coo 0 EPA/Other <br /> R - <br /> LU d State l <br /> Z <br /> V EPA/CNher <br /> L ; <br /> J Additional Descriptions For Materials Listed Above - K Handling Codes For Wastes Listed AboveLU <br /> ' <br /> d c d x <br /> 10 15 Special Handling Instructions and Additional information r -� ��/I j <br /> P USE' +[�lriv Ft'ytav�ral+5 a'o' F� <br /> 16 GENERATOR'S`CERTIFICATION I hereby declare that the contents of this consignment are Fully and accurate y described above by proper shipping name and are classified packed <br /> marked,and labeled and are it,all respects in proper condition For transport by highway according to app moble international and national government regulations <br /> J <br /> If I am o large quonhty generator I certify that! have a program m place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> d 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 /> +n <br /> and the environment OR if I am a small quantity!generator I have mode a gaoith effort io minimize my waste generation pnd select rhe bast waste management method that is <br /> cc available to me and that I can afford •- t t <br /> 0 l r <br /> IrPnniieeddf/Typed Name Srgnature E r Month Day Year <br /> w -71 111 1 CA <br /> T 17 Transporter i Ackno4cl ement of Receipt of Materials, I <br /> R / / <br /> LU A Pnnied/Typed No / Signature �- f Month Day Year <br /> LU N + <br /> LU 5 <br /> P <br /> U- 0 18 Transpo-rTerl Acknowleclement oVRecee t of Materials <br /> 0 T Panted/Typed Name Signature Month Day Year <br /> LU E <br /> Q R <br /> I <br /> tJ F 19 Discrepancy Indication Space <br /> Z_ A <br /> C <br /> I <br /> 20 Facility Owner or ODeratOr Cer4l6atlan of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> j I Printed/Typed Name / Signotvre�/lf { / Month Dayy Year <br /> IDO NOT WRITE BELOW THIS LINE <br /> DISC & 2A 02ll/99) e cr oor our <br /> EPA 87022A 1 c cc�c_ ampule ccv 0 nis cosy^=no senc^o )TSC wnrin 3D aays } <br />