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Skate of California—Environmental P,wechon Agency <br />'Farm Approved OMB No 2050-0039(Expires 9 30 991 See Instructions Oil back a� <br /> Please print or type Form designed for use on elite f 12 pitck nage 6 Department of Toxic Substances Control <br /> 'writer , Sacramento California <br /> UNIFORM HAZARDOUS _.6eDerator s US EPA ID No Manifest Documentl I, -G 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST / ► ( (� r Lli 1 s , off snot required by Federal law <br /> 3 Generator s Name and Mailing Avrts /� r A State Manifest Document Number A <br /> 5221 <br /> CD �J j V B State Generator s ID <br />�^ 4 Generators Phone Z_ Tri t tt , t <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> LO <br /> co i x r , r' r r " h r <br /> O Transporter s Phone "-I wt�l i <br /> O <br /> au 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> ljQ I I I I I F Transporter s Phone a <br /> 9 Designated cihir Name and S tq Address 10 US EPA ID Number G Stoic Facility s ID <br /> � H facility a Phone <br /> �.i'.s-345-9043 <br /> Q12 Containers 13 Total 14 Unit <br /> V 11 US DOT Description)including Proper Shipping Name Hazard Class and ID Number] No Type Quogtity Wt/Vol I Waste Number <br /> aF'i rtr "IP sl 5, 1`y Yv,�i 1 r t Stole 23 <br /> r <br /> EPA/Other <br /> o N b State <br /> co E <br /> EPA/Other <br /> A c State <br /> U R T <br /> co O <br /> R EPA/Other <br />'tocii d State <br /> Z <br /> f EPA/Other <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> 2 <br /> O a €)! b <br /> ii ' <br /> W <br /> oc c d <br /> a <br /> Q <br /> Z 15 w <br /> Special Handling Instructions <br /> nstructions and Additional sInformationO 4,- <br /> N <br /> AN .S` <br /> J [rte 7.,C <br /> z <br /> /CZ 11 % is.' ` <br /> �CJ ftGF/[C <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that i6e contents of this consignment are fully and accurately described above by proper shipP mg name and are classified packed <br /> Vmarked and lobeled and are in all respects in proper condition for transport by highway according to app#icable international and notional government regulations <br />' If I am a large quantithagenerator 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 economicallyy <br /> � practicable and that I ve selected the practicable method or treatment storage or disposal currently available to mwhich nimizes the present and future threat to human health <br /> and the environment OR J I am a smaquantity generator I have made e mi <br /> a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br />'O Prmtteeld__/Typejd/rNoome L.gnature ��� (._+� �� �,� Mont Day �Y@Jar <br /> Z #s iM S1 P's T6+'�, 1. 1�� L _ V,/ P <br /> w TT 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> a F Panted/T N. Signature' on ay") f"Y>igr <br /> w t f G -) <br /> LLI <br /> iL 0 18 Trans otter 2 Acknowled ement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> L <br /> � R <br /> a <br /> U 19 Discrepancy Indication Space <br /> LU <br /> � f <br /> A <br /> C <br /> 20 Facdpty Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as naiad in Item 19 <br /> Printed/Typed Name j Signature Month Day Year <br /> -TY <br />' DO NOT WRITE BELOW THIS LINE <br /> r�i.. G"cN[IZ?.70r2 �ti, <br />