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$role of Coiffornio—Environmental Protecrlon Aaency <br /> PC.Apptoved OMB No.2050-0039(Expires 9.30-99) See Instructions on back of page 6. Department of Toxic Subsrances Cohn <br /> Please print or typo. Form designed for use on ef1N 112•pltch)ypewrltvr, US Sacramento,California <br /> UNIFORM HAZARDOUS Generate r'e EPA ID No. Manifest Document No. 2. Page I Information in the shaded areal <br /> WASTE MANIFEST Q 17 ( �j 1� j'— Q �j of not required by Federal low. <br /> 3. Generator's Name d Mod1 g Add se I I • .4 , <br /> �j e/` c•l%)1 f�} � ��f 21'�p ©r �''�Kt�,x:^y ,.ag���ve:c�:r..'H1+4'W�2�K's4r r� L A ' t <br /> IA 4_ Generator's Phone )r ) l <br /> � f'7 -� .{ %�_,�r-,�.;7^ G.� W:210► .• C off, <br /> IN 1, Transporter 1 Company Name r 6. US EPA ID Number k hi c J <br /> m Q)I L-bST-e rt-9AtIPa441ory albbcl �t <br /> ti,.v �7 <br /> cRp0 � 3s q � . <br /> � n�d1a I <br /> OP .TNS: <br /> 7. Tramporrer 2 Company Name 8. US EPA 10 Num6er <br /> � pk.,• <br /> 1 :V 9. Design Md FaciCty ora .44Si dd-ros's' 10. US EPA ID Number <br /> T1. US DOT Descriprion(Including Proper Shipping Name,Masord Clow,and 10 Number) 12, Contalnere i 3. Total IA. Unit <br /> No, Type 0."nilly wt/Vol <br /> ' 61V a— <br /> E <br /> AIJCM ,a. CI ) �--Fl PIS r Po N b, <br /> 0000 E <br /> •er R <br /> C14 A <br /> o T <br /> eco 0 <br /> R <br /> W d, <br /> Z <br /> W <br /> U <br /> W <br /> N <br /> Z <br /> 2 <br /> dede <br /> Z t <br /> O anS. Special Handling Inelructlone d AddIrl rI Information <br /> W <br /> r� <br /> 16. GENFRATOR'S CERTIFICATION: I hereby d"m that the conlvnls o$16is consignment are Fully and oeeuralely deeeribed above by proper Shipping nome and are classified,packed, <br /> marked,and lobeled,and on In ali respects in proper condition for transport by highway according to applicable.international and nananal government regulations. <br /> if I am a large gvantiry generator,I cerrlfy that i hove a program In plate to reduce rhe volume and roxieiy of waste generated Po the degree I have determined to be economica11 <br /> practicable and that I hove Selected the rractRo6le method of iraatment,storage,or dlapaaal currently availoble to me which minimizes the pneent and fuNre threat to human health <br /> and the environment;OR,;F I am a small quantity generator,I have made a good foi+effort 10 minimize my wasle generation and 1sI the beal waste monagernenl meihad that IS <br /> available to me and that I can afforel. <br /> y Prinrad/Type4arno y Slgneture Menlh Day Year <br /> T <br /> 17. Tram nowled emvnt of Receipt of Materials <br /> LU e Prim ro Typed Nome $ignalure Month Day Ye: !_-: C 17a <br /> O0 18. Transporter 2 Acknowled emenr of Receipt of Materials <br /> RPrinroc ed Name. <br /> W 1 YP Signature Month Day Year <br /> � p I <br /> tJ 1 <br /> P. Dleereponry IndiemI <br /> ten Spae J <br /> r1c <br /> I 20. F till Owner or O eroror CertiFleaHon of ei t o hozardoue mereriala eavArm1hy 1114 man;6st excv nojecl in Item 19. <br /> T P,( r /Typed Name I Signet <br /> Month Day Year <br /> DO NOT RIE iIiELOW HIS N�. <br /> DTSC 8022A 14/971 JI*: -,)Cf 3Ei"{iS i;Mlw ;I; ! <br /> `rt�F . <br /> EPA 8700-22 'o: ?.C. ?o:; :0!7 i. "aerornnmo, <br /> ri Iiib.l rnnn sin nn� iaiir.r . r • ,. ,. ...., <br />