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State.of Colifornio—Environmental Protection Agency
<br /> `Form Approve MB No.2050-0039(Expires 9-30-99) See Instructions on back of page 6. Deportment of Toxic Substances Control
<br /> Please r type. Form designed for use on elite(12-pitch)h iter. Sacramento,California
<br /> UNIFORM HAZARDOUS 1 ierator's US EPA ID No. Manifest Document 1 2. Page 1 Information in the shaded areas
<br /> is not required by Federal law.
<br /> WASTE MANIFEST t 9
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<br /> 3. Generator's Name and Mailing Address Ivlpni
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<br /> LO A. Generator's Phone q lam- 7'_;0
<br /> sN 5. Transporter I Company Name 6. US EPA ID Number
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<br /> 7. Transporter 2 Company Name 8. US EPA ID Number
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<br /> 9. Designated Facility Nome and Site Address 10. US EPA ID Number i K
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<br /> V, 12. Containers •,13. Total 14. Unit *W
<br /> 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol pit►. um�7e -
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<br /> Z 15. Special Handling Instructions and Additional Information
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<br /> 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,
<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 /> If I am a large quantity generator,I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicallyy
<br /> CL practicable and that I have selected the rracticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heolth
<br /> rn and the environment;OR,if I am a small quantity generator,I have made a good faith effort minimize my waste generation and select the best waste management method that is
<br /> available to me and that I can afford. / t'
<br /> y Priffted'/Typed Nome Signature Month Day Yew.
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<br /> W T 17. Transporter 1 Acknowledgement of Receipt of Materials
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<br /> W r} Printed/Typed Nome Signoture nt/hh.., Day t Yeps:•
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<br /> U- 0 18. Transporter 2 Acknowledgement of Receipt of Materials
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<br /> V 19. Discrepancy Indication Space
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<br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name Signature "'D 1)
<br /> Month Da Year
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<br /> DO NOT WRITE BELOW THIS LINE.
<br /> lel!o•v TSDF SENDS THIS --OPY TO GENERATOR WITHIN --- !AYS
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<br /> EPA 8700-22 ^'-37 __-•o,c,co :-cv —s .noy .nc -enc -._ _
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