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*State of California—Enviro mmehaL.Protection Agency <br /> .Form' Loved OMB No.2050-0039(Expires 9-30.96) ( Y t See Instructions on back of `'�@ 6. Department ra Toxic Substances Control <br /> % print or type Fonn d�signed for use onlafi,(12-pi, iter. Sacramento,California <br /> • 1. Generator's US EPA ID No Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM` HAZARD60 is not required by Federal law. <br /> WASTE MANIFEST b Q Fj 2 �j 8 •' of <br /> 3. Generator's Name and Mailing Address ,��� I�11IGT5 tie p• A. State Manifest Document Number �A <br /> rte^" 901 <br /> 2oe)- .4 Sg2.d% 1412 C-L Rt4ku. bQIJ'Er, <br /> B. State Generator's ID <br /> I4. Generator's Phone ( ) 'S?D�i�L��4rY —ik, IWARG13,161ol.1 ,sr Il <br /> 5. Transporter 1 Company Name (/ 6. US EPA ID Number C. State Transporter's ID <br /> VwJ . A � 0 83 o v 3 9 D. Transporter's Phone Q /f <br /> 7'.Transporter 2 Company Name — ---8. US EPA ID Num r E, State Transporter's ID <br /> Transporter's Phone <br /> A-) Q G. State Facility's 9. Designated Facility Name and Site Address 10. US EPA ID Number rh''s ID 1 <br /> � .N icA't., W�►�7� N1v�JA�-,�hkk �Y '1'D o 0 qi 6i <br /> Y),�` 0 �% /�' OLD 5k*f t-Z V1D f H. Facility's Phone <br /> u 7c.-f�M G-r9 32,V� T o v o 6 I I rt <br /> �q 12. Containers 13. Total 14. Unit <br /> LO Z 11. US DOT'Descrieffort(including Proper Shipping Name,Hazard Class,and ID Number) rNo. T Quantity Wt/Vol I. Waste NumberState' PA/OtherN E I ��A ? bo 5 (I�Ag r oy ►D 01010,210 <br /> o d '� o <br /> 00 N b. State <br /> 03 <br /> yN R EPA/Other <br /> d A <br /> O T C. state <br /> 00 1 p �,, <br /> 1\ ' A !`.l 3 EPA Other <br /> Zd State <br /> w <br /> U EPA/Other <br /> W <br /> L <br /> Z J. Additional Descriptions for Materials Listed Above K. Handling Co s <br /> Han des for Waste fisted Above <br /> LU <br /> Q <br /> Z <br /> O 15. Special Handling Instructions and Additional Information . Alt <br /> Z <br /> Uj <br /> I— <br /> Liz - I)� it, <br /> --n 16. GENERATOR'S CERTIFICATION: I Famby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> J <br /> V pocked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I arks 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 <br /> d economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> N m <br /> threat to human health and the environents OR, 9 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that I can afford. <br /> S' Month <br /> nth Day Year <br /> O Printed/Typed maL 1,-A �' o -4 t7 <br /> U <br /> Zt 17. Trans entof Re rter 1 Ackrtowled emi t of Materials <br /> LU O A Printed/T Nome Signature Mordh Day �Year� <br /> ltLU <br /> ro, i�1,;t ti <br /> LU p 18. Transporter 2 Acknowled of Recei Materials <br /> Materia <br /> rll Printed/Typed Name Signature Month Day Year <br /> LL <br /> O e <br /> N19. Discrepancy Indication Space <br /> Q <br /> U FA <br /> Z C <br /> I <br /> L <br /> I 30. Focil' r or'Operator Certif' 'on of recei 'bf hazardous materials covered b is nifest except as noted in Item 19. <br /> Year <br /> T Printed/T No / Signatures ' Month Day <br /> r- <br /> DO NOT WRI E BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 1 95 (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A <br /> ( / ) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />