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k -State of California Enviionmental Protection Agency <br /> form Approved OMB No,2050-0039(Expires 9-30-99) <br /> Pleas rint or See Instructions on ba5k of 3 6. <br /> P type, form designed for use on elite(12-pitch)yr_..;iter. Departmenit of Toxic Substances Can <br /> $acfamenlo,California <br /> �r�tx's US EPA ID No. Manifest Document No. Page 1 Information in the'shaded areas <br /> �: U�IFRM HAZARDOUS <br /> rr STE MANIFEST r is not required by Federal law. <br /> Of <br /> J. Generators Name and MaHing Address <br /> ry dti 11�� �1 State DQanifest Document Number <br /> �r y 4 is 21 54546 <br /> w • Axa tQUT <br /> `O B„.Stole Generotor s lR' <br /> s' r^ A.+Generators PhoLiqne )t t_ C �lr <br /> V} , <br /> LO <br /> N JS.,Tronsporter 1 Company Name b. US EPA ID Number <br /> G State Transporters ID Reserved.] <br /> o Ai4iEfi�CAN�(AL LkY 1+°1fA:�s r O)i ; A L 0 0 0 8 � 7 � � D, Transporter:Phone V <br /> 7. Transporter 2,L Company N <br /> A.rame 8 US EPA ID Number - E, 5)ote Transporter's'ID[Reserved.) <br /> J <br /> Q <br /> F. Transporters Phone:` <br /> Q 111 <br /> ,"9psi�tip�e FgiFJity Nt acuuJ$ite Addres}Z 10. US EPA ID Number G. State aci ly's ID <br />).iJ. vG C fM L71 f tjAf4 I P r 'Xe <br /> v Z 5WG CLAUS ROAD <br /> O R I V E R 8 A N ,0,A 951367 H. Facility's Phone � <br />-•(� �l L .) •� .t 1116 209-86.3-4 181 <br /> V11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> 1\11. _ _. .,_ No. T e Quanti Wt/Vol 1. Waste Number <br /> o. .. --.. .. , <br /> nate <br /> G - 00 1 T TEPA Zi er ,. <br /> N E <br /> b. <br /> E State <br />- /,..- <br /> C14 A EPA/Other <br /> c. <br /> coO .0 State <br /> R <br /> >Y EPA/Other <br /> LU d, <br /> t— <br /> Z State a <br /> w ,. 3 <br /> V EPA/Other <br /> .' w <br /> "! ON J. Additional Descriptions for Materials Listed Above <br /> t K. Handling Codes for Wastes Listed Above <br /> a "OILY.WATEt� a. 01 b. <br /> : w <br /> 'J <br /> i:. Q c, d. <br /> 0 15. Special Handling Instructions and Additional Information <br /> Z � ��CLOVES ' <br /> S17 c 2� 5. > ,R rC,Q'I <br /> ss-t EMERGENCY f'�IOltil" :lly-fit e fifl 1; no n c, CC�, <br /> 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,packer), <br /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> tf I um a range quantity generator,`I certify}hat I have a prcgram in place to reduce the volume and toxicity'of waste generated to the degree 1 have determined to 6e economimlly <br /> N practicable and that I have selected the practicable method c f treatment,storage,or disposal currently available to me which minimizes the present and future threat to human hecabh <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 /> O .available to me and that I can afford. <br /> >- i rinted/T ped Name r Sign tura 'U IF ant Day year <br /> E ILI,, P) <br /> (5 T cons or`ter-1 Acknow ed ement of Receipt of Materials l <br /> R <br /> w A Pri ted/TypG4-f Signature <br /> � S ame r Month Day <br /> w s Year <br /> ' r <br /> ` l� <br /> ss_ 0 18. Trans orter 2 Acknowled ement of Receipt of Materials <br /> 0 <br /> w T Printed/Typed Name Signature <br /> E Month Day Year <br /> V) R <br /> < <br /> V F 19. Discrepancy Indication Space <br /> Z A - <br /> C <br /> t <br /> l 20. Facili net or O erator C anon of rete' t of hazardous materials covered b his manifest ext f as not d <br /> ✓T Printed pe me <br /> Y /A A , signora , y <br /> L /W nth D� Year <br /> 74i 1 <br /> LSO NOT WRITE BELOW THI LINE. <br /> Yellow: TSDF SENDS THI$ COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99 (,Generators who submit hazardous waste for transport out•of-state, <br /> 'EPA$700-22 ^:;st produce completed copy of this copy and send to DTSC within 30 days l <br /> r' <br /> r <br />