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State of California—Environmental Protection Agency <br /> t Form Ap_priproved OMB No-2050-0039(Expires 9-30-99) See Instructions on back of page 6. <br /> Please nt or type. Form designed For use on elite(12-pitch)ty- rifer. Department of Toxic Substances Control <br /> Sacramento,California <br /> F3. Generator's <br /> NIFORM HAZARDOUS 1;��erator's US FPA 1D No, Manifest Document No'--,, 2. Page 1 Information in the shaded areas <br /> ' WASTE MANIFEST u{[ r jJ !/, ;N' ? isnot required by Federal law. <br /> Name and Mailing Address f� fast Docum <br /> �f \V ()'l ! ( A. State Me ii ent;Number <br /> O � " *✓ r�l l i B. State Generator's ID <br /> 4. Generator's Phone,4(fl 4. —v f � � <br /> ii �_.. 16' <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State.Trans <br /> porter's ID[Reserved,] <br /> ili td4 Y 3. ll t�,f %JAI 9 E 'Y' Lrt3 Ct iµ1 f 4 (° $ fel Il ! �? ] r <br /> O , --, , <br /> O <br /> D. Transparter's Phone, { <br /> 7. Transporter 2 Com an N <br /> P P yame 8. US EPA ID Number E. State Tran sporter's ID[Reseved.J <br /> - <br /> Q F. Transporter's Phone <br /> V 9 �> '¢w � � IS'ajjttSifR4# �fsfss j 10. US EPA 1D Number G. StateVa+tift's'� � <br /> d <br /> .! <br /> Z 5.r';'fi,.F[,�CLAUS �.ALa � - � ` <br /> : <br /> Z <br /> 0 �til'tiEI�efAN , Cis X;1367tr � � �3 .I °� r 11. Facilityr n <br /> r3&s I <br /> V11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total I4- Uni{ <br /> p{�.l�r��ss�t, ss�y 1�p ,�L11��ll �77 rr ss�.�ra4�3 (i�li{,fiR ttYty� C��} ` No. T pe Quantity Wt/vol I, Waste.IVumberr,,, a. i�iFJ3 �l c+4 p,ry rls'-s:. ,(ti ta'�.r 4F, "1�sl�'^�.o3 r Iw �.I zaSe rd�.r State <br /> 1.C <br /> tj <br /> J <br /> p'1 'EPA/other <br /> E <br /> b <br /> 00 E state . <br /> CA EPA/Other <br /> c. <br /> mO State <br /> R EPA/Other <br /> ' w <br /> ad. <br /> or <br /> * <br /> Z Slate <br /> V <br /> y EPA/Other <br /> ' J Additional Descrip' nts .os ed Above K..Handling Code Listed Above <br /> t . � <br /> Q.. a. L <br /> W <br /> Z <br /> 0- 15. Special Handling Instructions and Additional Information <br /> EMERGENCY f"F1 tJZ—:2 -667--6�'3 5y <br /> 1 LU <br /> r <br /> M <br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and occuFataly described above by proper shipping Homo and are classified,packed, <br /> V marked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> ' J <br /> I f I am a large quanli generator,I certify hal I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economic 11 <br /> Practicable and that I have selected the practicable method o treatment,storage,or disposal current) available to me which minimizes the resent an hrh <br /> Qd and the 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 wastemanagementmethod thatisO available to me and Ila,I can afford. <br /> } Prinled/T ted Name <br /> Y i Signature ,•;� <br /> V f - a r fr ]" �r Month Day Year <br /> iZ '/. (" f. C' eek . =r ✓'`"`r ` ,: . �.,�'" �. � <br /> (� B 17. Trans orter I Acknowledgement of Receipt of Materials <br /> ce A Printed/T p d Name Signature <br /> S fir' ,/ Month Day Year <br /> LU P !'I <br /> O0 18. Transporter 2 Acknowledgement of Receipt of Materials r' <br /> R Printed/T ed Name <br /> Lu yP Signature Month Day Year <br /> Q R <br /> LV F 19. Discrepancy Indication Space <br /> Z A <br /> C <br /> I <br /> L <br /> —I 20. Facili Qss'ner or n--4or Certi{icalion of racei t of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature <br /> Month pay Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) <br /> EPA B700-22 Yellow: GENERATOR RETAINS <br /> 4 <br /> I <br /> F <br />