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,tate of C'olife,�yQ_'��_Environmental Protection Agency <br /> Farm a No.2050-0039(Expires 9.30-99h See Instructions on back of : 6. Department of Toxic Substances Control <br /> Pleaseprinl oatype. Form designed For use on elite(12-pitch)fyN ..,ter. Sacramento,California <br /> �,Ajooq17016XIJ <br /> Ge-ter. is US EPA ID No. Manifest Document No;: 2. Page I Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal low. <br /> WASTE MANIFEST `� �_ ( of� <br /> 3. Generator's Name and Mailing P�drest <br /> A.'Stoic Manifest Document Number n /�:: <br /> f �-��I" "t{'in �(1 B. Stora Generotor's ID <br /> LO 4. Generator's Phone ) <br /> S EPA ID Number Sfate Tronsporler's ID[Reserved) <br /> cv 5. Transporter 1 Company Name O O „ f <br /> h •l D.. Tr ns otter s Phon <br /> 0 p tJ f <br /> 0 <br /> oa 7.4T ­­rt,.�2rk.mp.ny Name 8. US EPA ID Number E.}State Transporters (Reserved] ry <br /> ' <br /> P" Ypa er s.,Ph.- <br /> Q Slat Faaih Y ID-. R X tr cr <br /> V 9. esignatej�Facility Name and Site Address 10. US EPA ID Numbermerqryt � h>°�. L <br /> Zaog: � vA� vt �J" <br /> )o i <br /> {� 12 Containers 13. Toal 14 Unit <br /> U11. US,DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No Type Quantity Wf/Vol tt' s hs <br /> LtUGS Wfi> •1c rr�v16 <br /> QEfs � j <br /> 3 0 (�,r��uCl? I cc/e,der ( T .•. <br /> N E b. <br /> act E EPA/�1 s <br /> 04 <br /> A <br /> Vc. <br /> APh V "ext <br /> aPyO NIq GCO SU C <br /> .� <br /> R � A <br /> Stow �. <br /> w d. <br /> Z EPA/Otberfk' <br /> r <br /> j lk <br /> V <br /> Lu - K. Handling Code3 fat Wastei Lilted(Al ave' s !y a <br /> N JcAdditionalDescriptionsForMaterialsListedAbove <br /> Z r F r - ¢e e ;3,'s s~�h d; <br /> Ocl� . <br /> Si .. �•F M1t r ix } - f• fir. }' <br /> uj <br /> L"p""`f <br /> Z 15. pecial Haprf ling Irsstruci ns a d Additional formation i/`- r% _ ? J-.•j <br /> !�` r �° �dlt <br /> OJSell�ul !cr p/r(.cr� %�'^'� � �_ <br /> Q <br /> Zs {!�r P V'��f•x�fNr d.{ �l '7h� -�[f�' L <br /> w c <br /> proper ship ing name and ore <br /> Q )6 marked,and s CERdFandTIO in all erespyedsclore that the in proper condition contets of or is contransport ni highway according g toand rappli able international ately described above yand notional gave nment regulations. pocked, <br /> V <br /> IF I am a large quantity generator,I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> Q_ practicable and that I have selected the practicable method of treatment,storage,or disposal currently ovailable to me which minimizes the present and future threat to human health <br /> Ln 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 /> cle available to me and that I can afford. <br /> O Signature Month Day Year <br /> Prinled/Typed Na e <br /> V .. f <br /> Z ^` <br /> w ... 7 <br /> Ur T 17. Trans otter 1 Acknowledgement of Recei 1 of Materials , Month Day Year <br /> A Printed/Typed Name <br /> wN 111 <br /> s P� <br /> LL_ 0 18. Transporter 2 Acknowled ement of Re cei t o Materials Month Doy Year <br /> R <br /> 0 Prinled/Typed Nome Signature <br /> T <br /> W E <br /> rn R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> 1 20. Facili Clor O eraCertification of receipt of hazardous materials covered b this manifest except as note in Item Month Day Year <br /> T Prinled/Ty dName / ,dr Signal re a�� <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A(1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />