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form Approved OMB No.2050-01 39,Expires 9.30.99) „ t.. bee Instructions on back of page 6. Please print or type. Form designed for use on elite(I 2-pitch)typewriter. N P 9 Department of Toxic Substances Con-c Sacramento,California UNIFORM HAZARDOUS1. r •°tors US EPA ID No. Manifest Document N, 2. Page 1 Information in the shaded eras I - 0 0 Q F 1 9 9 1 a 0 .2 is not required by Federal low- WASTE MANIFEST _ � i�r�tvr�RI Len*pfd M ilin% d• A. Shta Manifest Document Number •: .' 4+ c�r� `ATY,9T�lr^E 7F CALir t?Rt3IIt " :i21424407 31 _ CH.�IIN1r i, .� - an .5 0 9 tl°vCR?�N r CA B. Stale Generators ID v A. Generator's Phone (209 942-7730) - - - 1 1 C14 �,5. Transporter 1 Company Name 6. US EPA ID Number G State TranspoMr's ID[Reserved.) 00 6 31-ICJP HAZARD3 SOLUT 10143, INC. C A 0 0 0 0 5 4 6 4 9 7 D. Transporters Phone r ;.`�.8Q0) ,16—?449 7. Transporter 2 Company Name E. State Tn:iimVorter's tD Reserved) - P P Y B. US EPA ID Number - QI Transporters Phone U 9• Designated Facility Name and Site Address _ ~ j g H 10. US EPA ID Number G. SIaM Facihys ID Q AE&C, INC_ aZe 12067? HUI•PPAI& D Ali E. H. Faabys Phone HAYWAT-1), C 9s1,=4: 0 :, .3 2 9 1 1 9 9 3 ` 4 • . t310)429-1129 Q12. Containers 13. Total 14. Unit „j;.,. U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantify Wf/Vol I. Waste Number Z a.cJr,atc Poly=hlorinsted biphe::grla, liqu.Zd, 9, Stare 3 Ca EPA/Other _ E 1 D p = N N b. slate . m E R EPA/Other r v A - C.o T state 00 O R EPA/Other ac LU d. state . U EPA/Other Z J. Additional Descriptions For Materials listed Above IC Handling Codes for Wastes Listed Above _ -p a light balle�t containing PCS'° a. 6• t In .: _ - .. - Y -LU C. d. Z 15. Special Handling Instructions and Additional Information Q APPRO>;TArCE PFiUMCTIVE CLOTHING Z nEHEFGENCY CONTACT: 000) ?46-7449" E 3£E E_R.G_ PAGE 4171 y 16. 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, Jmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. If I am a large quonti generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical J ty practicable and that 1 hove selected the practicable method of treatment,storage,or disposal currently cvailablp to me which minimizes the present and Future threat to human heal n and the environment;OR,if I am a small quantity generator,I have made a good Faith effort to minimize my ste generation and select the best waste management method that is available to me and that I can afford. Prints Typed _ . Sig re Month Day Year Ir Z -- - / Q L R 17. Transporter 1 Acknowled ement of Receipt of Materials Printed/Typed Name q Signature Month Day Year u P 14 -A- 0 18. Transporter 2 Acknowledgement of Receipt of Materials D T Printed/Typed Name Signature Month Day Year r.s E R 19. Discrepancy Indication Space F A C 1 L 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. T Printed/Typed Name Signature.-" ` Month Day Year Y l . DO NOT WRITE BELOW THIS LINE. Yellow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, .EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days i