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Stoo of Cahforgw—Envsronmentol PTgtdction Agency <br /> Form Approved OMD No 2050-DO39{Expires 9 30 99) See Instructions on bad e 6 Department of Toxic Substances Control <br /> Please print or type Form designed r use on elde`f12 p ter - j Sacramento California <br /> _ 1 <br /> F <br /> RM HAZARDOUS ' 1 Generators US EPA ID No Manifest Document No 2 Page 1 Information In the shaded areas <br /> s no required by Federal low <br /> STE MANIFEST of a <br /> I <br /> Nome <br /> _an Mailing Address -I ]�t !, ,� P`:-ry A Stab Mam_Fasf Document Number" a. <br /> �,1 „3�'A Y G.. �;� ,,_.f ..,�( �_-. �`�r `�` i4..-`�Yr✓'s n.. w! �.�s. f S y <br /> B State Generator s ID <br /> nA Generator s Phone ( 4 <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID~ <br /> W) <br /> rr>~ <br /> as = li}" I ` t + ra_ ' i - "� = D'Tronsporteet.Phone _ t <br /> O (203 sF F <br /> co 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID ` <br /> f Transporter s Phone <br /> 9 Designated Facility Nome and Site Address 10 US EPA ID Number G State Fa ildy s ID <br /> - t,. t .41 <br /> t _ 1 ,rl -ice H Facility's Phone ` 'I <br /> J 12 Containers 13 Total I Unit <br /> a 11 US DOT Description in <br /> on(including Proper Shippg Name Hazard Class and ID Number( <br /> V No Type Quantity Wt/Vol ] Waste Number <br /> f�Z a State I <br /> f <br /> __ _ J t s Q O _ EPA/Other <br /> G <br /> c't E b State <br /> o N <br /> co <br /> coo E <br /> v R f EPA/Other <br /> Q A c State <br /> o T <br /> 0 O <br /> R EPA/Other <br /> w d State <br /> Z <br /> LwJ m EPA/Other <br /> W v <br /> J Additional Descriptions for Materials Listed Above K Handling Codes For Wastes Listed Above <br /> a b <br /> V) OILY WA7'rF'' , <br /> LU <br /> J � <br /> Q � _ <br /> Z 15 Special Handling Instructions and Additional Information I <br /> Q - ti'- - 1 - I - ' - - - - - t 1 ' J <br /> Its T r 7�, r <br /> LU <br /> F< � <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurat ft described above by proper shipping name and are classified pocked , <br /> V marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulotions <br /> f <br /> IF I am o Iorge quantity generator I certify that I hove a program in place to reduce she volume and toxicity of waste generated to the degree I hove determined to be economicol)yy <br /> to <br /> practicable and that I have selected the rpct,cable method of treatment storage or disposal currently available to me which minimizes the present and future threat to humors heatth <br /> and the environment OR d I am a sma I quantity generator I have mode a good Forth effort to minimize my waste generation and select the best waste management method that Is r' <br /> ovmla6le to me and that I can afford <br /> OPrinted/Typed Name ! r'� Signor rs 1, 1 r �� onth�,I Da cYepr <br /> W 1 17 Transporter 1 Acknowledgement of Receipt of Materials /j <br /> LLJS Panted/Typed ame ,Cry! _.,/�' Signature /�/ ` tel ! �Mioi7l rDay. ) �X or, ' <br /> D 18 Transporter 2 Acknowledgement of Receipt of Materials r <br /> TPrinted/Typed Name Signature Month Day Year <br /> u� E <br /> Q R w <br /> U 19 Discrepancy Indicotion Space <br /> Z F <br /> A , <br /> I <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous matertals covered by this momfest except as noted In Item 19 <br /> T Primed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br /> i <br /> DTSC 8022A 1A/97f Yellow GENERATOR RETAINS <br /> EPA 8700-22 `1 <br />