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State of Cahforn,a—Environmental Protection Agency ' Form Approved OMB No 2050-0039(Exp+res 9 30 99) See Instructions on back of page b Department of Toxic Substances Control Please print or type Form designed for use on ebte 112 pitch)typewriter Sacramento California UNIFORM HAZARDOUS 1 Generators US EPA ID No Manifest Document No 2 Page ] lnformation in the shaded areas WASTE MANIFEST 'p s ( s f; fr r is not required by Federal law IL OF 3 Generators Name❑rid Mailing Address IT x'1!4"o r A Stole Manifest Document Number 22782943 cry4 OLr) �Ie, i]t ty5i/� t< 1 ryy 8 State Generator s ID ' ^ A Generator is Phone ()�X( ] 6) Ln (V 5 Transpolter 1 Company Name 6 US EPA ID Number C State Transporter s ID(Reserved] r _ p ,� f 1� jr�/ �C L�E r{ fid �i f/'L� � f•i r D Transporter s Phon' �.( Fc�`C✓.{G[ CIDV 7 Transporter 2 Company Name P P Y 8 US EPA ID Number E State Transporter s iD[Reserved Q F Transporters Phone [.J Desi qi d Fanld? eine and 5,a Address 10 US EPA ID Number G State Fauhty s ID Vii KIK L I IUB) {'_ Z ��t��.I�41 S W H Facile s Phon 11 Q tl IA V tanr � I 1 US DOT Description(including Proper Shipping Name Hpxard Class and ID Number) 12 Containers 13 To { No Type Quantity Wt/Vol I Waste Number l� U,'f� '.Yr - ,(�Lt'�C !'v.S [�ifJ,�F_ �F /{ (.1✓� State G L t t f v, I</ +� e� L� i ( r y�"" �� 'ERA/Other,, , 1 r CV O N b Skate co co E V R EPA/Other , I0 7 O T c State # 00o O R EPA/Oiher LU tr d State Z LU EPA/Other Li ' Ado(lllongl Des�gt,�ns for Materials Listed Above K Handling Codes For Wastes Listed Above R. a , f 6 LU /{ C d ' 0 15 S ectal Ha Inng/fnstruciions and 4cldit,onal Int rmaiion f "� /' �J�K.. f ce",C .t ;�F'�r Y-^�.L�'cc4.�/�,.+5 t t, I• f !� '^ ! !l1l.F,S (,�a 14T /441 i(7/N/-(x,, tr rr,I a z1;4L 4 LLI r �l11;- f ff ) 5 Q16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed V marked and labeled and are m all respects,n proper condition for transport by highway according to app icable international and national government regulations If I am a large quantity generator I certify that 1 have a program in place to reduce the volume and toxicity of wade generated to the degree l have determined to be economicolly eco practicable and that I haveselected the proclicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health and the environment OR if I am a small quantity generator I have made a good fodh effort to minimize my waste generation and select the best waste management method thal is C�, available to me and that I can afford y O PrintedrT ped Nxi Sa nature (� ! ! f /`� (r g ] Month Day Year Z C C•�d �f r; t� (,_,�t� l..xt. d'�� -� �i 0 _r; w T 17 Transporter t R iler 1 Howled ement of Receipt of Materials s _ N Printed/T ed`Najne Signature �� ' !f ,f ua III g j 1� Month Day Year 1 P W- p 18 Transporter 2 Acknowledgement of Receipt of Materials ` RPrinted/Typed Name Si LU T 9 nature Month Day Year cn E Q R U 19 Discrepancy Indication Space Z F — A C 1 20 Fac htt Owner or Operator Certification of receipt of hazardous materials covered b this manifest e-xcept as noted in Item 19 Printed/Typed N—orn � f } Signature %Y�_ Month{ ay Yea f DO NOT WRITE BELOW THIS LINE Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS DTIC 8022A 11/991 {Generators who submit hazardous waste for transport out of state EPA 870022 produce completed copy of this copy and send to DTSC within 30 days]