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State of California—Environmental Protection Agency <br /> F srm Aporoved OMB No 2050-0039(Expires 9 30 99)4 See Instructions on back of page 6 Department of Toxic Substonces Contra) <br /> Please print or type Form designed For use on elite f 12 pitch)ypewrtter Sacramento California <br /> I <br /> I Generator s US EPA 1D No Manifest Document No / 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> } �y r q C� of t 's not required by Federal law <br /> WASTE MANIFEST <br /> C {— CJ U { U 0 tS ! `&F r� t/ <br /> 3 Generator s Name and Moiling Address jts 0 �^ 1 k State Manifest Document Number /� �] ° <br /> At NC/P Y�FC L I G (� 6 <br /> ��� }} 5--,P-3 <br /> t ' '� i t r F y <br /> L� P 11 --,P.3 1 B State Generator's 1DLO <br /> f1��if3 uta <br /> LO4 Generators Phone ' I ] 3LL <br />' CV 5 Tr nsporter 1 Company Name 6 US EPA ID Number C State Transporter s ID(Reserved <br /> LO <br /> � D Transporter s Phone q C,�/ ry ?y! t ` " / t <br /> o- <br /> a, 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's ID(Reserved <br /> I <br /> F,Transporter s Phone 1 <br /> V 9 Desi na ed Fa i Nome d Site ddress 10 US EPA tD Number G State Facility s ID <br /> d Ut I �"ixtAi r <br /> Z �C tj() 6(ttVS H Facility s Phone ! <br /> Q 12 Containers 13 Total 14 Unit <br /> 1 1 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) a <br /> V No Type Quantsy Wt/Vol I Waste Number <br /> Z o Alvlv 11 w z 6( State '] 1 <br /> [TPA/0ther <br /> 3 G CjlVu fr G U T r <br />' C'4N b ` StateCID <br /> , <br /> O d <br /> co E <br /> EPA/Other � a� <br /> v R r <br /> A state` w <br />' o T <br /> EPA/Other <br /> R <br /> w d State <br /> F <br /> VEPA/Other y <br /> w <br /> J Additional Descriptions For Materials Listed Above I" K Handling Codes for Wastes Liste"d Above ` <br /> P <br /> sA <br /> ce <br /> � ' ` I tis ` c ° � � � d ' <br /> Q15 Spec ip I andlir�tInsirrrtll cpch4ns a ddition I Information D f�] � y� • 7 ' rrr4y <br /> {/ C J {r�uf4 fL,.vt�'� <br /> Z <br /> W <br /> 1 1 7 <br /> 16 GENERATORS CERTIFICATION I hereby declare that the contents of this conegnment are fully and accurate)y described above by proper shipping name and are classified packed <br /> Vmarked and labeled and are in all respects in proper condition For transport by highway according to applicable international and notional government regulations <br />' J <br /> If i am a large quantay generator I certify that I hove a program in place io reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> n- practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and Future threat to human health I <br /> and the environment OR if I am a small quantity generator I have made a good!V6 fort to minimize my waste generation and select the best waste management method that is <br /> avuilable to me and that I can afford <br /> OPn /JTy am Signatu e ` Month Day Year <br /> je <br /> W T17 Transporter Acknowled ement of Receipt of Materials <br /> oe R <br /> LLA p Prsnt T ed Nam Signature Month Day Year <br /> CJ ,y <br />' LLJ <br /> si a 18 Transporter 2 owledclement of Receipt of Materiais ! <br /> R Pnnted/Typed Name Signature Month Day Year <br /> T <br /> LU E <br /> V) R <br />' 19 Discrepancy Indication Space <br /> F <br /> Z <br /> — A <br /> C <br /> I <br /> L <br /> 20 facile Owner or Operator Certificatiorsof receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> t j % <br /> Pnnted/Typed Signature orifi Day Year <br /> 0a!( <br />' DO NOT WRITE BELOW THIS LINE <br /> d <br /> f 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 completed copy of this copy and send to DTSC within 30 days} <br /> 1 <br />