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State of California-Environmental Protection Agency <br /> form Approved OMB No.2050-0039(Expires 9-30"991 See Instructions on back of page . Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite f 12-pitch)typev— r� <br /> Sacramento,California <br /> UNIFORM HAZARDOUS 1. Gs or's US EPA ID No. Manifest Document No, 2. Pogo I Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST + - of 11 <br /> 3. Generator's Name and Moiling Address A Siotela Z646si Document Number <br /> � 2296"'61 <br /> ✓ B State Genercfor's'JD <br /> 41 <br /> ,to 4. Generator's Phone <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C State Transporter a 1b[Reserved] <br /> Wald{`:i1if:A+�l ilt:i f S' f4:SefS i i' iq]f 7 it ?' 'r't Fi 114 <br /> 0 - - U Trdnsporter's Phone 1hd <br /> x-rte <br /> 7. Transporter 2 Company Name B. US EPA ID Number El' State Transporters ID Reserved] <br /> Q F Transpe�iter's Phone f <br /> 9e tDe;gAoted"FG;ili�yt!dme nlydlSfts.Addr' * 10. US EPA ID Number G Staf�;Fa tty�C ID(- <br /> . ..r......� St <br /> t � I H Focrhl Phopa <br /> C - A - �Cr <br /> �! <br /> Q <br /> 11. US DOT Description fintluding Proper Shipping Name,Hazard Class,and ID.Number] 12. Containers 13. Total 14 Unit ?' <br /> No. Type Quantity Ws/Vol 'f; Woste,Numher <br /> a. N011+3-RC RA .f4A?-AR130U3 WA87-E LIQUID <br /> G OILY WATER ) 0 0 `I .T T x EPAlo,he <br /> E <br /> N b. Smte x Y <br /> Ir S 4c. <br /> v RTEPA/Other <br /> r, A R <br /> J <br /> T C. -state <br /> O " <br /> R EPA/Othef-:.� <br /> d' State <br /> EPA/Ofherw � <br /> W <br /> J. Addiiionaal Descri cions For Materiats Listed Above <br /> �pyy, f y {�i - , K Handling Codes for Wastes cited Above� w <br /> 4k. <br /> 15. Special Handling Instructions and Additional Information <br /> E MERGE NCY PHONE: 2004367-M15-4 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurate) described above b proper ship in name and are classified packed, <br /> Q Y P p PP g p t ed, <br /> V marked,and labeled,and are in.all respects in proper condition for transport y highway according Io applicable 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 determined to be economieafly <br /> practicable and that I have selected the practicable method of treatment,.storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> 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 waste management method that is <br /> available to me and that I can afford. <br /> It <br /> Printed/Typed Name Signature <br /> Month Day Year <br /> A17. Transporter!Acknowladr ement of Receipt of Materials <br /> Y Prints7r'ypad Name Signature Month `Day Year <br /> A. <br /> is. transporter 2 Acknowle ement of Receipt of Materials <br /> Printed/Typed Name Signature Month Day Year <br /> I <br /> '. Discrepancy-indication Space <br /> tilt Owner or Operator Certification of retei t of hazardous materials covered by this manifest except as noted in Item 19, <br /> /Typed Name Signature Month Day Yaar <br /> DO NOT WRITE BELOW THIS LINE. <br /> )9[ <br /> ' Yellow: GENERATOR RETAINS <br />