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State of Cal fornio—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page G Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite(12 petchl typr yr Sacramento California <br /> UNIFORM HAZARDOUS 1 ator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> is not required by Federal low <br /> WASTE MANIFEST `�� 0 Q ff-2 of I <br />' 0 tj� ko QjC P A State Manifest Document Number <br /> 3 Generator s Name and Mailing Address Iy F.� {'�P�,rC' <br /> >, (jo B Stale Generator s ID y <br />'"' d b C ${}1� a Liu <br /> 4 Generator's Phone ! >- , <br /> N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID(Reserved] <br /> LO <br /> o AMEFfiKAke LEY WAISWOILA L 11 r) .9- D Transporter's Phone <br /> 0 <br /> a� 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID(Reserved] <br /> F Transporters Phone <br /> U q� �+� ' f a $�sa fTylp�Fy� 10 US EPA Ib Number G Siateaf'+oci 40 a ) ; r =r r <br /> S 101)01 <br /> Z 7} H Faahty.+�s Pyh�yon�ey�# } y�lei,,a <br />--0 i41 Wr-rdJANK, CA ala�,yq."[3i 4' � �. � �� i d'.'a�:4r"A73J1347 a�J" i <br /> "-' 12 Containers 13 Total lA Unit <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) <br /> U No Type Quantity Wt/Vol I Waste Number <br /> a I`,tON-�`4a(Fih�^f�aZ.P�nRDOU!q WAS'Tt ]_I'��°;I0 State 221 <br /> r f Chit Y ,,VA i f-R 3 T 6 � EPA/Other <br /> lG� <br /> O N 6 State <br /> co E EPA/other <br /> R,"I <br /> A c State <br /> o T <br /> co O EPA/Other <br /> R <br /> ILU d State <br /> LU EPA/Other <br /> V <br /> w <br /> V J Additional Descrip�ti'o�nsp foorr'M�attesriyalls Listed Above LL K Handling Codesrfyor Wastes Listed Above <br /> `'Q1L,�YarYA'91 jR a 4941 6 <br /> N I <br /> LU <br /> cse c d <br /> 1Q � , <br /> Z0 15 Special Handling Instructions and Additional Information <br /> a til!0Vr-S <br /> Z r-MERCalw`NCY PHONE 09 657-88537 <br /> w <br /> 16 GENERATOR'S CERTIFICATION I herebydeclare that the contents of this consignment are full and accurately described o6ove by proper shipp mg name and are classified packed <br /> Vmarked and labeled and are in all resects in proper condition For transport by highway according to applicable international and national government regulations <br /> 'N IFI am a large quontiry 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 economicallyy <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently avoi 6le to me which minimizes the present and future threat to human heahh <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 /> a available to me and that I can afford <br /> Pnted/GTyYpfed fi F <br /> rN4 'I+r LAY Y^Y!r SignatJurr/e <br /> Day Year <br /> {/ C- <br /> Z Z Nome <br /> T 17 Transporter 1 Acknowled eine 1 of Receipt of Materials <br /> ILU A Printed/Type ome Signature _ n]}a Day Year <br /> W $ <br /> as_ B 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Pnnted/Typed Name Signature Month Day Year <br /> U.1 E <br /> u]' R V 19 Discrepancy Indication Space <br /> F <br /> — A <br /> C <br /> 20 Fault Owner or O orator Certificapon of recei t of hazardous materials covered 6 this m,,n except as noted in Item 19 <br /> Pnnied/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> 'DTSC 8022A I1/99) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />