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Y <br /> Please print or type (Form designed for use on elite(12 pitch)typewriter) Form Approved OMB No 20540039 Expires 5-3488 <br /> UNIFORM HAZARDOUS 1 Generators US EPA ID No Manife t 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST 1.C A 9 s 1 1 8 ai of 1 I <br /> is not required by Federal law <br /> 3 Generators Name and Mailing Address A State Manifest Documertt Number p <br /> tticklaW Propertiee (ftgal 604) <br /> P.O. Dau 13648 , Bacra to, CA 9SBS3-4648 r <br /> H Stat®i3ener cPa fD ?1 ri ;w� <br /> 4 Generator's Phone(916 } 921-1100 I <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C'State Trans net's tD� - 15 <br /> 7 ! J % " 3 D Trans orter`s Phoria M" > z' <br /> 7 Transporter 2 Company Name a US EPA ID Number lE State Transportor's ID <br /> I F`�Transporter'a Phoni <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G`State Facility's iD_ <br /> 0020tva-Xakiaa, Inc.. <br /> 1414 S. First Stmt H Facility's Phone <br /> Yall:uw, WA 98901 1 W I A 1 0 10A9 A 1'717 1 17 15 (S09)-4525 <br /> 12 Containers 13 14 <br /> 11 US DOT Description(including Proper Shipping Name, Hazard Class and ID Number) Total Unit Wa9te No <br /> No Type Quantity Wt/Voll, <br /> G a Hazardous Wast Solid <br /> E <br /> N K.O.S. OWE 9189 4 6 D ` :11° 2 <br /> E <br /> R b +� <br /> o •9r y ^� <br /> R <br /> d " <br /> 4 <br /> } <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above, <br /> a1t a!! � ummd fii�?' +ii' r, <br /> George Ckmvwwl w (916) 668-S.3Og/ On 6) "O-SUO t 24 HoWS <br /> 15 Special Handling Instructions and Additional Information <br /> Stardaard for paatrolmm races bydrocarb=a <br /> 16 GENERATOR'S 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 according 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 toxicity of waste generated to the degree I 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 quantity generator I have made a good <br /> faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford <br /> Printecirryped Name Signature Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Pnntedrryped Name Signature Month Day Year <br /> N <br /> P <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T <br /> Printedriyped Name Sig <br /> E nature Month Day Year <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> c <br /> I <br /> L <br /> I 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T Printed <br /> Y !Typed Namenature Month Day Year <br /> Sig <br /> EPA Form 8700-22 (Rev 9 86) Previous editions are obsolete Reorder No 960 Lab Safety Supply Co <br /> 4 <br /> GENERATOR COPY <br />