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�+III�M.eLCI$omio-Environmenlol iry <br /> dorm Approved OMB No.2050-00 r6s 9�$0 sb * ttee Instructions on back of page.6. <br /> f.. f Y p � - Department of Toxic Subslanoes Control <br /> Please.print or type. Form designed fo on elete(2 J peA Sacramento,California <br /> UNIFORM HA US G` :u EPA D o. Manifest Document No.,+ 2. Page h Information in the shaded areas <br /> ` is not required by federal law. <br /> r WASTE MANIFEST 9of <br /> 3. Generator's Name and Mailing Address <br /> 14ELAML XX ' - 9, a <br /> C4 <br /> UAJIA <br /> 4. Generators Phone ( J <br /> g -953 - 406 ,4 <br /> S. Transporfer 1+Comparry Name ._ 6. US EPA ID Number <br /> i f r <br /> joQ 7. Transporter 2 Company Nome S. US EPA ID Number <br /> V <br /> 9. Dila cn Facil' me <br /> canited SAddres s10. US EPA ID Number <br /> I o r en . <br /> J 255 Parr Elvd. <br /> U. Ri.chnMd,CA. 94$01 IC'IA 'G 0 9 2 <br /> 11. US DOT Description(including Proper S.hi m Name,Hazard Class, 1D Number 12. Containers 13. Total 14_ Unit <br /> Z P' f gShipping } No. Type quantity WI/Vol <br /> °NC V-RCRA Hazardous Waste ScjIid_ <br /> `I 3 E Waste Empty Sttrr�'f- Tank. 1 T � P <br /> / / C �} ♦♦ <br /> 00 N bf l,`JI CJ 4✓♦ 4+TG E) /D J DI/� <br /> �. I fife !! <br /> R <br /> A <br /> .iT C. <br /> 00 <br /> O <br /> R <br /> tr - <br /> u1 <br /> Z d. <br /> Z <br /> w <br /> V <br /> w <br /> ttu <br /> x - <br /> J <br /> Z <br /> -_ 0 15. 5 int <br /> a eeHkandlin <br /> a nyTru r d Additional Inform ion, <br /> wear is when o k arauaneSOarCeS O3.gn1ti0n, Alwd <br /> Z U G.S•T. 'S 24 lir. Cc>1ata `t Nash��ar�.�S�e� x� Fh Q9 .Q,s��940 - <br /> LU <br /> J 16. GENERATOR'S CERTIFICATION.- I hereby declare that the contents of This consignment are fully and accurately described above by proper shipping name and are classified, <br /> r <br /> Upacked,marked,and labeled,and are in all respects in proper condition for transport by highw^-y according to 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 <br /> d economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> (n threat to human health 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 <br /> waste management method that is available to me and that I can afford. <br /> 0 Printed/Typed Name kk Sign Month Day Year <br /> I _ <br /> tZii 8 17. Trans orter 1 Acknowledgement of Recei 1 of Materials <br /> NPrinted/T'yped'I4ame - r` ; Signature_ Day Year <br /> LLI <br /> LLT 0 18. Trara orter 7 kcknowled ement of ffecei t of Materials <br /> LL T Printed/Typed{dame' Signature ' Month Day Year <br /> 0 E <br /> R <br /> LU <br /> in 19. Discrepancy indication Space <br /> Q F <br /> V A <br /> Z C <br /> 1 <br /> }, 1 20. Facility Owner or O ralor Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> s <br /> T Printed/Typed Name Signature Month Day Year <br /> V <br /> DO NOT WRITE BELOW THIS LINE. <br /> I 8022A (1/95) <br /> 1 EPA {1700---22 Yellow: GENERATOR RETAINS <br /> EPA <br />