Laserfiche WebLink
State of CaliPiip—Environmental Protection Agency <br /> Form Appi6viA OMB No.2050-0039(Expires 9-30-99) 5�ee Instructions on back Of ---ie 6. Department of Toxic Substances Control I <br /> Please print.ortype. Form designed for use on elite(12-pitch(t 'ter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> lJNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. erator's Nome and ging Address A. State Manifest Document Number <br /> 24520 <br /> 1 J !� ���`A `�'' �,r r 130.1 rCJs B. State Generator's ID <br /> V) <br /> !N• ) ALrC✓ <br /> v7 4T�enerator's Phone - <br /> t\ <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tronsporter's ID[Reserved.] <br /> Go <br /> u7 <br /> D. Tronsp ter' ne <br /> �� <br /> � f _� <br /> 7. Transporter 2 Company Name 8. US EPA ID Number- E. State Transporter's'1D{Reserved I <br /> 0� <br /> F. Transporter's Phone - <br /> Q <br /> V esignated Faciliand Site Ad ess //,� 10. US EPA ID Number G. State acility's ID <br /> V d ter <br /> Z / <br /> `V Q 12. Containers 13. Total 14. Unit - <br /> V <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste,Numb ec <br /> Z a. State <br /> S O <br /> C' go V � EPA/Other <br /> ?� <br /> E <br /> C. N b. State <br /> m E <br /> -4 R EPA/Other <br /> A c state <br /> o T <br /> C) O <br /> R EPA/Other <br /> w d. State <br /> Z <br /> EPA/Other <br /> V _ <br /> w. <br /> Z J. Ad ' obdl DesErf ti ns for M ial 'steel A e t a i�, K, Handl C s'r Lis[d ave` <br /> a <br /> w <br /> t. d. <br /> Q <br /> O 15. Special Handling Instructions and Addi"ti al Information ! /E,u . h . +� <br /> d 1Vir'"Dnn1cyo <br /> 2�r�{ �-x-C•.� �4 �, �Y 3 �ro�-Fay e'Zd.. � n, �. <br /> Z !_oma- -,On: JY1r�jn o I r,a� e�e,�a 5 K46 n �2& <br /> 16. GENERAT004 CERTIFICATION: I hereby declare that the contents of this consignrAnt are fully and accurately descr ed above by proper shipping name and are classified,packed, <br /> Q marked;and labeled,and are in all respects in proper condition For transport by highway according to applicable international and not, <br /> government regulations. <br /> V <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 economical�lyy <br /> d practicdble and that 1 have selected the radiwble method of treatment,storage,or disposal currently available to me which minimizes the present and future threafio human%health <br /> rn <br /> and the environment;OR;if I am a sma I quantity generator,I have made a good faith effort to minimize myw e generation and select the best waste management method that is <br /> 10 O available to me and that I can afford. <br /> At <br /> } Printed/Typed Name _ SiMure Month Day Year <br /> Z t C H-4Z- r TH—;C C N '� U —7 a (o 1 016 <br /> LU T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LE DD 1ja <br /> 1 <br /> LU e Printed/Typed Name _ Signature /Month Day/ �tYear <br /> / <br /> $ V 17 V s0 <br /> 8 18. Tran orter Acknowled ement of Recei t of Materials <br /> 0 R Printed/Typed Name Signature Month Day Year <br /> LU E <br /> R <br /> l�J 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> I <br /> 1 20. Faci ity Owner or Operator-Certification of recei of ordous materials covered b tis manifest exce t as noted in Item 19. <br /> T Printed/ ype Na a Signature j + (�Alonth Day Y�epr - <br /> i <br /> L' 1 1. ` �•-- 1 <br /> DO NOT WRITE BELOW THIS"LINE.. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A (1/99) To: P.O- Box 400, Sacramento, CA 95812-0400 <br /> EPA 8700-22 9 <br />