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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 1e 6. Department of Toxic Substances Control <br />Please print or type. Form designed for use on afire (12 -pitch) rites Sacramento, California <br />DO NOT WIMTE BELOW THIS LINE:-� i <br />ti I <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />1/99 (Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A <br />(1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />/' <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page I <br />Information in the shaded areas <br />�UW1FORM HAZARDOUS <br />is not required by Federal law. <br />&Z WASTE MANIFEST <br />-I <br />of <br />3. Generator's Name and Mailing Address <br />5s7.7—y <br />A. Stale Manifest Document Number —25791-7 <br />B. Slate Generator's ID <br />4 Generator's Phone ( ": I "%- "•' <br />S. Transporter 1 Company Name 6. US EPA ID Number <br />C. Stab Transporter', ID f Res_rved.] <br />_. ,. .., <br />... <br />D. Transporter's Phone <br />7, Transporter 2 Company Name 8, US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9. Designated Facility Nome and Site Address - 10. US EPA ID Number <br />G. State Facility's ID <br />-- <br />H. Facility's Phone. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />!2. Containers <br />13. Total <br />Quantity <br />1 d. Unit <br />Wt/Val <br />I. Waste Number <br />No. <br />Tye <br />I-fAZr J J� Wr;-��-F .. �, :4_,. N. 0 S. <br />,� ... <br />. ... <br />EPA/Other <br />'� i'VFd:i;Tuc PG 11 T . 10317 ! ( ERG-*.1.7 <br />G <br />1vr0 f4.F SOL~Jr10N'S 24 -./GAL) <br />/ <br />1 <br />l.J r'o <br />E <br />b <br />State <br />N <br />E <br />EPA/Other <br />R <br />A <br />State <br />T <br />O <br />EPA/Other <br />R <br />d. <br />Stale <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />b. <br />d. <br />15 Special Handling Instructions and Additional Information <br />1_! iK1.1l7 ,1T! L) .t- IaLi t -:Ji ;�_t.!}'Iti,y: -e t <br />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, packed, <br />marked, and labeled, and are in all ...pests in proper condition For transport by highway according to applicable international and national government regulations. <br />I am a large quantity generator, I certify that have a program in place ro reduce the volume and toxicity of waste generated to the degree have determined to be human ice y <br />I= method r, treatment, storage, or disposal currently available me which minimizes the present and future threat ro human health <br />practicable and that selected <br />p <br />I am a the practicable <br />waste <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort b minimize my waste generation and select the bast waste management method that is <br />available to in. and that I can afford. <br />Printed/Typed Name' - <br />Signature ..> - <br />Month Da' <br />Year <br />t <br />T <br />17 -,-Transporter I Acknowledgement of Receipt of Materials-.�'yT� -- _ <br />1 <br />'A <br />Printed/Typed Name," <br />/ �/ <br />Signatures t <br />Month Da Year <br />Y <br />.7 � -- <br />0 <br />18. Trans •ier2 Acknowledgement of Receipt of Materials - <br />! <br />T <br />Printed/Typed Name <br />Signalure <br />Month Day Year <br />E <br />R <br />j <br />19. Discrepancy Indication Space <br />A <br />•�:. <br />E <br />20 Faali Owner or Operator Certification of .... i i of hazardous materials.eovered <br />b this manifest exec i s noted ie Irons 19. • <br />T <br />Signature <br />I Printed/Typed N�ms! <br />DO NOT WIMTE BELOW THIS LINE:-� i <br />ti I <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />1/99 (Generators who submit hazardous waste for transport out-of-state, <br />DTSC 8022A <br />(1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />