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State of Califomio—EfivironmeMi Agency <br />Form'sAp roved OMB No. 2050-0039.(Expires;fSdq See Instructions on back of 6. <br />Q _ Department of Toxic.Subsfonces Control <br />Please pnM <br />or type. Form designed %r use --tae (12pitch) r. SocrameMo, California <br />UNIFORM HAZARDOUS 1. Generator s US EPA ID No. Manifest Document No. 2. Page, 1 information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST of <br />3. Generator's Nameand Mailing Address <br />Ir04 C�i,UrC3 ®� J�'�'V5. �G' TcriNcrG°ut�s4S1' �.®NcJ <br />4. Generator's Phone <br />5:. Transporter 1 Company Name 6. US EPA ID Number <br />a m —if13 Mill <br />-+ <br />Transporter 2 <br />� mpatty Name 8. US EP ID Number <br />��I !tom she- /✓l�.0 <br />i DOT Description Chlclu ng Prop <br />10:' US EPA ID Number <br />or ReGel of <br />I <br />NA <br />rri /Typed Name' <br />Month t. <br />Year <br />W <br />"5 <br />t <br />4 <br />E,All35° <br />0 <br />18.'Trans r2 c <br />o Recerf'J�Aateafob <br />�L <br />Ir <br />PriMed/Typed Name <br />i a <br />Signature <br />,� <br />Month : <br />Day Yew <br />, ti n <br />, <br />i <br />fc <br />'y2:r <br />1,?.,Discrepancy Indica ion <br />Spoca.. fY <br />I <br />L, <br />1 <br />20. FacilityOvmer or OperatorCertification <br />of recei of.hazardous materials <br />covered by this manifest,except <br />as noted in 1 19, <br />Printed/Typed Name <br />SignatureMomh <br />Day` ' • Year ' <br />Y <br />DO NOT. WRITE BELOW THIS LINE. <br />Blued <br />GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />DTSC 8022A (7/92) <br />To: <br />P.O. Box 400, Sacramento, CA 95812-04.00 <br />-EPA 8700--22 <br />