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State of California—Environmental Protection Agency <br /> Form Approve OMB No.2050-0039(Expires 9.30.99) See Instructions on back of Page 6. Department of Toxic Substances Contra <br /> Please print of type. Form designed for use on elite(12-pitd writer. Sacramento,California <br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Manifest Documen 2- Page 1 Information in the shaded areas <br /> is not required'by Federal law. <br /> WASTE MANIFEST A - O 471-, 1 5'+ �� t of 1 <br /> 3. Generator's Name and Mailing Address . State Manifest Document Number cc b <br /> PESO—BO I L.D I148 R• PROPE:RT Y MGM i". 9910 4 8 <br /> o _.1 E. CHANNEL. ST. , S OCKTON', C. 4 9`321242' B State Generator's ID <br /> sA <br /> sA <br /> A. Generator's Phoneill, <br /> (V 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> sA <br /> D. Transporter's Phone <br /> o <br /> SHOP HA7AFJ)S S11122 TOL-Li. INC, ['; I >t. IA I O . f 4-:, 14 1 '? :' 11 �r.�.:: l+`=► <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.} <br /> Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number La. State Facility's ID <br />'N.c POLLUTION CONT'HOL I111)LISTP I C S <br /> (D Z= `5485 AY FOR DF?I VE. H. Facility's Phone <br /> C)O M I LL.I NGTON, TN ,3805• F' Pl r 4'i 4't� 7 1 �� <br /> Q12. Containers 13. Total 14 Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol 'I. Waste Number <br /> State <br /> li;, NIJi`J—R�.l�r=f Nf Zf�RDGi.lS LJf15TE L.IQUII) <br /> ~ i REFIR I L�l.�fw ROT I ON 011,.., TRACE13 OF F RE:ON) U) 1 1? NI EPA/other <br /> � <br /> 3 <br /> N E b 'State <br /> o N <br /> 00 <br /> coo E EPA/Other <br /> v R <br /> CN <br /> Ac State <br /> o T <br /> 000 O EPA/Other <br /> R <br /> w d. State <br /> L <br /> Z EPA/Other <br /> LU - <br /> tA J. Additional Descriptions fprMaterials list 4 .' K, Handling Codes for Wastes Listed Above <br /> Zb. <br /> owc a c. d. <br /> Z 15. Special Handling Instructions and Additional Information <br /> O <br /> < (-1PP ROPR I ATE- PWJTF_-CT I VF.: CIAT•E-I I G <br /> Z 't i_N'IE RGE NCY C-tJP• TACIJ <br /> _ c3EE E. R. G. f--''{•bE 17 1 <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 /> Umarked,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 program in place to 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 <br /> and the environment;OR, if I om 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 /> Oavailable to me and that I can afford. <br /> PrintedfTyped Name Signature i Month ^D ay cyYear <br /> r <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LLJ <br /> j Printed/Typed Name Signature nth Day Ye r. <br /> LU s ':i J..F'1!Z':. hl lylE.l F=(�� r %'/�1 o <br /> U- 0 18. Transporter 2 Acknowledgement of Recei t of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> hE <br /> R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> l 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Nome Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) ' Fellow' GENERATOR RETAINS <br /> EPA 8700-22 <br />