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Slate of Ca)-forma—Enveronmental Protection Agency <br /> Yarm Aaproved OMB No 2050-0039{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 elite f 12 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page I Information in the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST IC-14ofr: . ; w5 j <br /> 3 Generator s Name and Mailing Address / A State Manifest Document Number <br /> /}I'sc� B State Generator s ID <br /> 10 4 Generators Phone ( J L % ^7 Pf{', r <br />' N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporters ID IReserved I <br /> LO <br /> O D Transporters Phonef <br /> .'r+� _+ f, r- r, r! } tLf I �� �tl / Xf JAI/ -[ %� <br /> 7 Transporler�l Company Name ' 8 US EPA ID Number E State Tronsporfer's'1D[Reserved} <br /> J I <br /> j f 1 F Transporter',Phone <br />©U 9 Des>gnated Facility Name and Site Address 10 US EPA ID Wumber G State Facility s ID <br /> ZZ ��`tivt tla�1L C r ( �lititir � 'coca �u�4 <br /> H Facility's Phone J <br /> to <br /> J f.. <br /> 12 ontame4- 1 J Total 14 Unit <br /> l.J 1 I US DOT Description(including Proper Shipping Name Hazard Class and ID Number[ No Type Quantity Wt/Vol I Waste Number <br /> 1 I <br /> Lt. <br /> _ /' !fJ/d� l��fr1� !rcj,Cr ��U( f/� State�.%� <br /> M C <br /> 3 <br /> }}Ca � � EPA/Other A <br /> o N b — State <br /> coOE <br /> R EPA/Other <br /> v A <br /> c <br /> O T State <br /> ooa O <br /> R EPA/Other,, <br /> ac <br /> LU d State <br /> Z <br /> LU <br /> V EPA/Other y <br /> w <br /> J Additional Descriptions for Materials Listed Above K Handling Codas for Wastes Listed Above <br /> b <br /> c d <br /> aU - I = t <br /> 015 Special Handling Instructions anld Additional Information / 1 <br /> O T-fr1U4Cc 1 { <br /> Z <br /> wLr/�r <br /> J+ 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of Ibis consignment are fully and accurately described above by proper shipping name and are classified packed <br /> Vmarked and labeled and are in all respects m proper condition For transport by highway according to applicable international and nahonal government regulations <br /> I ZJ If I am a large quantigenerator,I certify that I hove a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to 6e economically <br /> rn ticable and that I h <br /> practicable ave 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 environment OR if I am a small quantity generator I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> i= available to me and that I can afford <br /> Prinld/Typed Name Signature I r Month Day Year <br /> w T 1'7 Trans Drier )"Acknowledgement of Receipt of Materials 4 <br /> R <br /> Lu <br /> A Printed/Typed Noma _ Signature Month Day Year <br /> N LU <br /> sa_ 0 18 Trans orter 2 Acknowled emenf 6f Receipt of Materials <br /> 0 RLU Printed/T ed <br /> T @. ame Signature Mont`n Day Year <br /> E / f/r <br /> V 19 iscrepcincy Indic`ahan Space ter ' <br /> Z F <br /> — A <br /> C <br /> I <br /> I f <br /> f 20 Fauh Owner or O orator Certification of receipt of hazardous materials covered by this manifest except as noted m Item 19 <br /> T PnntedJTyped�mg � �fY 1 Signature � Month Day Year <br /> ' / /^ f" / <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 hazardous waste for transport out of state <br /> EPA 8700-22 produce competed copy of this copy and send to DTSC within 30 days I <br />