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date of Colifomia—Environmental Protection Agency <br />'arm Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of r -6. Department of Toxic Substances Control <br />'lease Drinl or tvae. Form designed Ior use on utile IlApikh) ry mr. Sacramento. California <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />)TSC 8022A (1/99) (Generators who submit hazo rdous waste For Ironsporl out -of -stale, <br />PA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />1. Generator's US EPA ID No. <br />Manifest Document No. <br />2. Page 1 <br />Inforation in the shaded areas <br />UNIFORM HAZARDOUS <br />is nmot required by Federal law. <br />WASTE MANIFEST <br />of <br />3. Generator's Name and Mailing Address <br />A. Stale Manifest Document Number <br />3463 � <br />23463 <br />B. State Generator's ID <br />A. Generator's Phone <br />S. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's M (Reserved.) <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 />H. Facility's Phone <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />T .. .. <br />..... <br />stale -. <br />G <br />' <br />) `2 <br />EPA/Other <br />Nb. <br />Stare <br />E <br />R <br />EPA/Other <br />Tc. <br />state <br />O <br />R <br />EPA/Other, <br />d. <br />Stora <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 />c. <br />d. <br />15. Special Handling Inmuctians and. Additional Information - <br />- - <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper ship ing name and are classified, packed, <br />marked, and 1.6.6d, ad are in all respects in proper condition for transport 6y highway according to applicable international and notionaPgovernment 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 economically <br />and that 16Gave selected the method of treatment, storage, or disposal currently available to me which minimizes the future threat to human health <br />proctica6le proctico6le <br />and the environment; OR, if I am a small quantity generator, I hove made a good faith effort to <br />present and <br />minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />I <br />Printed y4sad t'I¢ i( A <br />Signature - <br />-- <br />^Month y✓ �.TDay ]yo <br />:/✓J <br />T <br />17.,' raps orte 1 Acknowledgemanl of Recd Gbf Ma rials <br />`.0 <br />APrfnted'Typed <br />Name __(- /. / �. <br />fignaluza <br />- -�--`—' <br />Motktbl D`ay." Y <br />P <br />R <br />18, Trans orter 2 Acknowled emenl of Rete 1 of Materials <br />T <br />Printed/Typed Name <br />Signature <br />Month Day. Year <br />E <br />R <br />19. Discrepancy Indication Space <br />A <br />C <br />20. Facili Ownder or Operator Certification of recei I of hazardous maNriois covered 6 this manifest except as noted In Item 19. <br />T <br />Printed/TypeName <br />signaNre _. <br />Month Day Year <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />)TSC 8022A (1/99) (Generators who submit hazo rdous waste For Ironsporl out -of -stale, <br />PA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />