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orare or �,aurornia-cnvtronmen rai rrorecnon Agency " <br />-Form Approvud OMB No. 2050-0039 (Expires 9-30-99)isy�`�[�j�,;`1' <br />Please print. or type. Form designed for use on elite (I2,1GI tyUri%rF',.. s <br />; e•F r <br />UNIFORM HAZARDOUS <br />1 • Generators US EPA ID No. <br />1. <br />If I am a large quonti 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 economical) - <br />practicable and that I have selected the practicable method of trectment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />he <br />WASTE MANIFEST <br />OA 0,102 1 47 <br />and 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 1 can afford. <br />3. Generator's Name and Mailing Address a (�] , <br />p¢nted/Typed Name <br />Syature r 1 ) - <br />6540 , A`J iTIN <br />ss.t <br />DAVE <br />LO <br />r.�s <br />a �`C,C IKTO'N Irl: 95215 <br />LO <br />171 Trans rter 1 Acknowled ement of Receipt of Materials C <br />ece, <br />4. Generator's Phone ( 2 0 9) 46 4 —6 0 ? 1 <br />N <br />Printed/Typed Name ] ,G Signature ,;' <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />Ol'Ln <br />tt f� y. ;gip INC./. n ry t <br />.r (''; r'�'-31St i. �i. spa iY ,J `rS li,e a'lsLY VV <br />aD <br />7. Transporter 2 Company Name <br />P P Y 8. US EPA ID Number <br />J <br />Q <br />V <br />a <br />Z <br />ae <br />0 <br />Q <br />V <br />Z <br />3 G <br />c�i E <br />0 N <br />oo E <br />-4 R <br />v A <br />o T <br />C U <br />R <br />Z <br />LU <br />V <br />LU <br />N <br />Z <br />0 <br />N <br />LU <br />a <br />Z <br />0 <br />a <br />Z <br />LU <br />J <br />is not <br />of <br />A. State Manifest Document Number <br />6. State Generator's ID <br />C. State Transporters ID <br />D. Transporter's Phone <br />tion 1ti the shaided :dreai <br />qui red by'.Federof law. <br />146043?.' <br />r�[ <br />y��ky rpt[, 1 <br />1� 6 V 4 4 j <br />E. State Transporter's ID (Reserved.] <br />I <br />F. Transporter's Phone I <br />9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br />y7 }y 050144 - - � C 0 0 94 t 1 <br />ra .. i -•r, +YT ST i'.T.r LLi SAN JG 3/+ % r i <br />22. a/�lrx:;�Yi2S' RD CAD059494310 H. Facility's Phone <br />.AN JOSE CA 94,133 800 45-.3358 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) 12. Containers 13. Total 14. Unit <br />No. Type Quantity Wt/Vol I. Waste Number <br />a. <br />'k A fiAZARDOUS WASTE LIQUID State <br />OIL, LdA'IER, SLUDGE( NOT DOT REGULATED) � TT '1 � �,. � r_ EPA/Other <br />b. <br />State <br />EPA/Other <br />c. <br />State <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above K. Handling.Codes for Wastes Listed Above <br />a. <br />14 I b. <br />15. Special Handling Instructions and Additional Information d <br />MFST R/T*1017048(54 0002-6.933-98 <br />ICY RESP x300-468-.17,60`` 24 FIR I. IF UNDELIVERABLE RETURN TO GENERATOR. <br />SK t;ORP AUTMORI ED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECF.SSA.RY. <br />—+ <br />Vmarked, <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully-andvccurately described above by proper shipping name and are classified, packed, <br />and labeled, and are in all respects in proper condition For transport by highway according to`{a}pplicable international and national regulations. <br />government <br />J <br />a <br />cn <br />1. <br />If I am a large quonti 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 economical) - <br />practicable and that I have selected the practicable method of trectment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />he <br />Cie0 <br />and 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 1 can afford. <br />p¢nted/Typed Name <br />Syature r 1 ) - <br />Month: Day . Year. <br />ss.t <br />U' <br />T <br />p <br />171 Trans rter 1 Acknowled ement of Receipt of Materials C <br />ece, <br />w <br />A <br />Printed/Typed Name ] ,G Signature ,;' <br />joont Dayfi YearLU v <br />P <br />w <br />U- <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials f r <br />O <br />R <br />Printed/Typed Name <br />i <br />Sitahature <br />Month Day Year <br />LU LO <br />Q <br />E <br />R <br />w <br />V <br />19. Discrepancy Indication Space <br />_ <br />ZA <br />F <br />C <br />L <br />~ <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered 6y this manifest ex sXoted•in Item 19, <br />T <br />Pri"ted/Typed Name —.I <br />L <br />Month Day Year <br />Y <br />� .' ! • % r'•- -.. -`� r_i �,,,- .�- � �.: �,. <br />// .. ��...---� Bey <br />..�' I � I � I � IG' � I�- " <br />DO NOT WRITE BELOV%( THIS LINE. <br />DTSC 8022A (1/99( <br />EPA 8700-22 Green: TRANSPORTER RETAINS <br />