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5 t of California—Environmental Protection Agency <br /> eiW1�AIIIRpvjdjPMB No.2050-0039(Expires 9-30-99) f See Instructions on back of le 6. Department of Toxic Substances Control <br /> Please print gr type.- form designed for use on elite(12-pitchl iter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generators US&A 1D No.- onifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal low. <br /> ( <br /> s _ til L. 010101118181 ':1� 3 0 f' 1 / of <br /> 3. Generator's Name and Mailingr ` <br /> Address A. State Manifest Document Number '�► <br /> C C, if lilf:441.13 <br /> 1 � Nt.lE"i I Fi �.►� <br /> G Of110 0N. 01 :f!j06!' 3 B. State Generator's ID a �s <br /> W) <br /> A. Generator's Phone 009 47,34,P0.1 <br /> -E,P0.1 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> h <br /> a <br /> 0 a D. Transporters Phone <br /> 0 <br /> all a 3• ._.� lit <br /> _ _ <br /> ao s I - - - <br /> 7. Transporter 2 Company Name 8. US EPA ID Number- E. State Transporter's ID[Reserve . <br /> C)Q F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US E A ID Num ber G. State Facility's ID <br /> Z ti ikJ� iVA9 y Q� �, f i it <br /> �., } V y 7► e7 ® ? Ifl. Facility's Phone f■ �� <br /> VA L VIJiII6`r r <br /> -+a 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers`'- 13. Total 14. Unit <br /> V V <br /> No. I Ty Quantity Wt/Vol ,L,'Wast®Number <br /> Z a. <br /> 0:+ 1,08, `•I, lair '1r,; I'.1t3I 1104AI_4T"Offl :'.i <br /> 3 G EPA/Other. <br /> 01011 00P101013 <br /> p N b. State <br /> coo E <br /> R EPA/Ocher <br /> CN A <br /> o T c. <br /> State <br /> a0o O <br /> R EPA/Other <br /> Lu d. State <br /> Z - <br /> U EPA/Other <br /> W <br /> - J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> 0 b <br /> LU TOS—LWTA IN ING MATERIAL <br /> c. d. <br /> t Q <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Z 4 Wff�o I:'IE'Kb`F_Fd(::'E' 6 E:SL 8,31-- 3617»E:1-'ta F;E.UVJN IX,FPA RE611ki In,R2 61L.1N <br /> IX F;tHf�UND 9319 'r.1L.V3 lrf ,AN t�ttF�NCa4C0 II'A 94113`3 PSHE.:3l0S hNi�f1l:(tt F?€�:tidi_IIhEMENe <br /> F ()+tii4�1:yE.D,sEp)A k:1) f-.ra!~E.I.E.I�? q <br /> II 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 /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J <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 /> 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 /> h 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 /> available to me and that I can afford. <br /> 0 <br /> V FPrinted/Typed_Npme J f Signature �� �, Month Day Year!� /j �'� - ' r <br /> Z :h r ., t--- <br /> w TR 17. Transporter 1 Acknowledgement of Receipt of Materials ' <br /> W A Printed/Typed Name �J Signature31 JAL <br /> Month Day Year <br /> S P <br /> w <br /> LL B 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> co R <br /> U 19. Discrepancy Indication Space <br /> , Z F <br /> A <br /> C <br /> I <br /> L <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 Month Day Year <br /> lY <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />