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'i - . — .. 1 — <br /> F, _J OMB No 2050-0039(Expires 9V 30 991 See Instructions on back of page 6 Department of Toxic Substances Control <br />' Please print or type Form[resigned For use on elite(72 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 /> is not required by Federal low <br /> WASTE MANIFEST �CIA L 1010190 V� � (7 � {u P of d r <br />' 3 Generator d Ak State Manifest Document Number <br /> s Nome an Marling Address _t ifs f[" F „t Tr * ,1'+� r <br /> lf� T'4L /��-i(�T• S , ti Lit 'iFF ^y x�(,� �e t <br /> 3 cJ�/ 1 H `4 h 1 L +.i t k i <br /> j ( 7 +� B`State Generator's ID <br /> 4 Generators Phone 'y �!c J� ! <br /> ocv 5 f -0 77 <br /> LO <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporier's ID[Reserved] <br /> " t r^rJ'1 xt t <br /> p D"Trons <br /> c? �A €`� ) ! U �� 7 "1 <br /> _ 7 Transparter"2 Company Name 8 US EPA ID Number E r State Transporfer,'s fReserved I- <br /> V <br /> Y <br /> F Transporler's'f'horie S, A ° rJ a"° *' "` mill S <br /> tel •,�^. �' •• � 3. f i, 1'i'", a iSSTf`�f t a.k,ds <br /> 9 Designated Facility Name and SiteAddress10 US EPA ID Number G iiSlole Facility s IDm <br /> d Evil +ij�Ut ilii"5i[I` sf y c a�Idol!, Q1 a <br /> 10 Ce 300 614+r6 <br /> � H' Fiii@c.i i s"Phro7n <br /> � n rL4fi CY b 1 Qr � � / 7 <br /> V <br /> 11 US DOT Description(including proper Shipping Name Hazard Class,and ID Number) 12 Containers 13 Total 14 Unit m K� Cytp`y <br /> No Type Quantity Wt/Vol d 'Waste Nu;hEV'4 $,° <br /> a G'VV'V' " V{/u] f� (/L' State`hw a n <br /> r t kit �•� ,. a4 <br /> � V �i� <br /> r7 � <br /> ri f1�" a ye y C3t5 r <br /> E � � <br /> IO N b <br /> °a <br /> co <br /> E <br /> EPA`/OtheFVRR m A� hY�{ �w'0 <br /> jv A <br /> c StateLsl�& �, `r <br /> I OT00 <br /> O CEPA/OtherF�ji-ry*7 <br /> Z <br /> dtt Pfd" T��u <br /> t <br /> LL, <br /> ts.i EPA/O liar ��, <br /> LILY <br /> r�r''''kd`k,i+i"5'i+`''T�`r27 '�i'k�i e" <br /> 1 kAddltionaf Descnplioni Fol Materials fisted AWVVr -� ti �r .+ t, s r*a `k" 33 T K fion[Ilirig Codei'foraY�asta Listed A�bave $ 'f"'7"rtt r" f <br /> R�' _ v iFi of ^fir Wl*l 1 o &d"rw.�Y ,. <br /> dX <br /> �" <br /> i ,'+ 'y"� d ♦# .,�{'�x a <br /> Q <br /> rra P 'air max, "wsQ la�:nk '�� sa ; r x k zts3sXsf�49, <br /> '1rx _ 6bx, a,' v, ^a�h�r� Pa +w <br /> Zr�`, A x <br /> 15Special Handling Instructions and Additional Information 1 fC l <br /> Q d/� ki•f,�ur.� r�4C`� lt°� 1J�ja�r15 UrieFtY,� f� y�� /�f'� Eftll�t � Z✓w`� 1 '36 <br /> j, <br /> Z �IGI �>♦'��L� �-r r �i�G!`4Ur1 <br /> )515107111 <br /> I 16 GENERATOR's CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descrsbed above by proper shipping name and ore classified,packed, <br /> marked,and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> J If I am a large quantiy 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 economically <br /> n practicable and that 1 have selected the proctica6le method of treatment storage or disp9sal currently available to me which minimizes the present and Future threat to human health <br /> I O and the environment OR if I am a small quantity generator I have made a good frition th ffgrI to minimize my waste generad select the best waste management method that is <br /> available to me and that I can afford �/" <br /> y. Printed/Typed N me /� Signat a Month Day Year <br /> Ir- <br /> R17 Trans orter Acknowled amen[of Receipt o Materials }rl <br /> � A Printed/T e Name Signature y <br /> Month Da Year <br /> R <br /> W a ) <br /> I.L. <br /> 6 18 Trans orter 2 Acknawled a int of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> LU E <br /> R <br /> laj <br /> F 19 Discrepancy Indication Space <br /> Z_ A <br /> C <br /> I <br /> L <br /> 1 20 Fa ility Owner or operator Certification of receipt of hazardous materials covered b [his manifest except as noted in Item 19 <br /> T Printed/Typed Named Signature / �/yJ� r Month Day Year�f <br /> I DO NOT WRITE BELOW THIS LINE <br /> Yellow d TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC 8022A (1/99) 1 (Generators who subm0 hazardous waste for transport out of stale, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days] <br /> 'C <br />