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Please print of type {fiorm designed for egg an elite(12 o,rch)ryPewr+rer) Form Approve., OMB No 2050 OC39 Expires 9-30 88 <br /> rGenerato <br /> FORM HAZARDOUS 1 Generator s US EPA Ip No Mamie*t 2 Paget Information to the shaded areas <br /> Documen No of is not required by Federal law <br /> ASTE MANIFEST 19181 1 8 5 0 <br /> s Name and Marling Address A State Manlf st c to rr� <br /> la I� portius (VAgal 6�; f <br /> X 13648, Saera�nt0 a CA 95853-4648 B State Generator's 1D r <br /> s Phone( 076 ) 921"1;80 (24 hours) I43Yi3f X01341 <br /> r 1 Company Name 6 US EPA ID Number, ti C State Transporter's ID Transporter's Phoneer 2 Company Name `8 US EPA ID Number E State Transporter's ID <br /> } I F Transporter's Phone <br /> 9 Designated Facility Name and Site Address 1D US EPA ID Number G State Factlitys ID, <br /> H Facility's Phone <br /> 12 Containers 13 14 <br /> w <br /> 11 US DOT Description(including Proper Shipping Name, Hazard Class and ID Number) No Type QTotal Unl Waste No <br /> „ I <br /> E a Hazardous W to Solid _ 00 A <br /> � h <br /> �y <br /> 127 <br /> N K.OoS. ORBS NA 9569 J LP <br /> R b at*,s r <br /> A <br /> T ' <br /> o <br /> R <br /> d ` <br /> e <br /> W1C Handling Codes for Wastes Listed Above <br /> J Additional OescrEptions for Materials Listed Above `� <br /> Splint-carlt,casisterlia gid,tri6 r VaP*r $xtrsatUa wells ' <br /> cmtawina a3dth unlciii� g am-t BnergencY , tact <br /> 'fie t er' I9i ;' 33 #6Z (91 66$-S3*0 t24 b0=8 <br /> AoMptanlve 0 iO-286-c ry <br /> 15 Special Handling Instructions and Additional Information <br /> Standard f tam petraletxRt range hydrocarbons <br /> 16 GENERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified packed,marked,and labeled, and are in all respects in proper condition for transport by highway accordsn5 to applicable <br /> international and national government regulations <br /> If I am a large quantity generator I certify that I have a program in place to reduce the volume and toxiclt�of waste tanerated to the degree l have <br /> determined to be economically practicable and that I have selected the practicable method of treatment storage, or disposal currently available to <br /> me which minimizes the present and future threat to human health and the environment OR if I am a small quant ,v Generator I ha+e made a good <br /> faith effort to minimize my waste generation and select the best waste management methoti that is available to me and that l can afford <br /> Pnntecirryped Name agent for WiCkland Signature Month Day Year <br /> r+ <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R Month Day Year <br /> A Prinled/T yped Name Signature <br /> 5 f a ,fir' <br /> P r , f i r <br /> ZZ <br /> e 1B Transpryfter 2 Acknowledgement of Receipt of Materials <br /> RSignature Month Day Year <br /> T Printed/Typed Name <br /> f <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this mantfest except as noted m Item 19 <br /> 07 PnntedrTyped Name Signature Month Day Year <br /> Y <br /> EPA Form 8700 22 (Rev 9 86) Previous editions are obsolete Reorder No 860 Lab Safety Supply Co <br /> GENERATOR COPY <br />