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State of California—Environmental Protection Agency r <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on oCk Of a 6. Department of Toxic Substances Control <br /> Departm <br /> 4r <br /> Pleasa prfnq't or type. Form designed for use on elite/12-pitch) rifer. Sacramento,California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA ID No. Manifest Document No. 2. Page 1 to formation in the shaded areas <br /> WASTE MANIFEST <br /> (_ is not required by Federal law. <br /> '' ti(J r of <br /> 3. Generator's Name and Mailing Address " m 0 �fs 4— A. State Manifest Document Number �y^ A <br /> r ^ V! ('J�.i'��rt L ^VS 9 <br /> -10j .d�Z B. State Generator's ID <br /> nA. Generator's Phone�O� Vb <br /> N 5. Transporter 1 Company Name r 6. US EPA ID Number-. C. State Transporter's ID[Reserved.1 <br /> h <br /> ao - <br /> ��y�--• 7. Tfahsporter-2 Company Name 8. US EPA ID Number E. Skate Transporter's ID(Reserved] <br /> T[ansporter',Phone <br /> �U 9. D ignored Facility Name and Site Address 10. US EPA ID Number G Ifgte Facility's ID <br /> � ta7) rt� c�Ci <br /> za w <br /> y�Q 11. USD T Description(including Proper-Shipping Name,H and Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> No. Type Quantity Wt/Vol 1.Waste Number <br /> �lil; f stares � t <br /> 3 UM 1 �t �s 1 P6.1 L L <br /> O t� (y1 r EPA/0 <br /> o N b. <br /> Slate <br /> coOE <br /> 4 R EPA/Qther <br /> C14 A <br /> o T C. <br /> State <br /> m O <br /> R EPA/Other <br /> oc S <br /> LU d. tate <br /> Z <br /> Z <br /> UJI <br /> V EPA/Other <br /> w <br /> V) J. A itional D scriptions for Maters s List Above K. Handling Codes for Wastes Listed Above <br /> Z0 Al M <br /> LU <br /> d. <br /> Z 150 ecialndli g Instructs s nd,Ai tonal Information <br /> Z <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,packed, <br /> V marked,and labeled,and are in all respects in proper condition fbr 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 /> a practicable and that I hove selected the practicable meth6d of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> V) 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 /> W available to me and that 1 can afford. <br /> O <br /> •nt /Type am Signal ' M0 <br /> 1th Dar Yea <br /> Z <br /> w T 17. Transporter 1 Ack'nowleAgement of Receipt of Materials <br /> RPrinte T e Si a re Month Da Year <br /> p LLJ <br /> l S. Transporter 2 A nowled ement of Receipt of Materials f <br /> 0 R ted/T ed Name i nature Month Da Year <br /> T nYP 9 Y <br /> U.1 E <br /> N R <br /> raj 19. Discrepancy Indication Space <br /> Z F / <br /> — A <br /> C <br /> f 20 Facili Owner or Operator Certific on of recei f of hazardous materials covered by this manifest except n ed' Item 19. <br /> T Pr ted yped Norge _ Signature / l Month ay Yeo <br /> DO NOT WRITF BELOW THIS LINE. <br /> t Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(l/99) (Generators who submit hazardous waste for transport out-of-state, <br /> produce completed copy of this copy and send to DTSC within 30 days.) . <br /> EPA 8700-22 <br />