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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 Or ge 6. Department of Toxic Substances Control <br />Please orintbr tvoe. Form designed lar use on elite (12 -Pito writer. Sacramento, California <br />DO NOT ITE BELOW HIS LINE.' - <br />(ellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br />lGeneratore who submit hazardous waste for transport out -of state, <br />DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />w <br />1. Generator's US EPA ID No. Manifest Doment No, <br />2, Page 1 <br />Information in the shaded areas <br />bi44*ORM HAZARDOUS <br />- <br />a ,.. 3 <br />is not required by Federal law. <br />WASTE MANIFEST <br />- - '"" <br />of <br />3 Generator's Name and Mailing Address <br />A. Stale Manifest Document Number <br />B. Slab Generator's ID <br />4, Generator's Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. Slate Transporter's ID [Reserved.] <br />D. Transporti Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. Stale Transporter's ID [Reserved.] <br />-- - - <br />F. Transporter's Phone - <br />9. Designated Facility Num. and Site Address - 10. US EPA ID Number <br />G. State Facility's ID <br />- - i.11. <br />H. Facility's Phone <br />11. US DOT Description (includingProper Shipping Name, Hazard Class, and ID Number <br />P Pe PF e I <br />12. Containers <br />13. Total <br />Qu "i <br />14 Unit <br />WI/Vol <br />I. Waste Number <br />No. <br />Type <br />a. ('OE F) t_.LE i.TPd!>' CrQ1"It'sQlrNP`5 N. C s. 13. ^,f <br />DM <br />State 1 _ 44 <br />l�I1 r 7�I� I 1jc'[I�ii- nfR U6Ct 1Y �Yf!r�.ii.-.M T 1:.1'.,'.' <br />/ <br />EPA/Other <br />G <br />'.l.i'F 1 f'::.rt lJN'�)iYER 3L:f irl :3#1i:;1_s <br />J <br />.. L(T.'01'.1 <br />l <br />E <br />N <br />6. <br />state <br />E <br />R <br />EPA/Other <br />T <br />state <br />EPA/Other <br />Q <br />J. <br />Stale <br />EPA/Other <br />J. Additional Descriptions For Materials Listed Above <br />K. Handling Lades for Wastes <br />Listed Above <br />t +s, <br />,... .. S <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information Q""{'- "'-"- <br />A 941 l`r C J <br />n <br />nnt are fully and accurately described above by proper shipring name and are classified, packed, <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consigme <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and nationaPgovernment regulations. <br />If I am a large quantity generator, I certify that have a program in place la reduce the volume and toxicity of waste generated ro the degree I hove determined to be economically <br />practicable and that( have selected the practicable method of treahnent, storage, or disposal currently available to me which minimizes the present and fuNm threat to human health <br />and the environment; OR, if I am a small quantity generator, I have made a good kith effort to minimize -My west, ga�ecatryn and select the bast wrote management method that is <br />availa6le to me and that 1 can afford. i' i ,-" __ <br />Printed/Typed Name <br />l <br />Signature /1� "'�^ <br />Month Day Yea <br />r <br />T <br />17. Traae orleF`1 Allmexi ement of Receipt of M tenets <br />R <br />Rrioted/Typed <br />Nama <br />�r <br />$'igna�� <br />Month Day Vaor <br />S <br />� <br />U <br />P <br />0 <br />I8. Tions a r t Acknowled arrant o Redei t o Materials <br />Printed/Typed Name <br />Signature <br />Month Day Veor <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />20. fac8' ,Owner ar O erator Cerlificationnof receipt of hazardous materials coveredL IN, manifest exc 1 as noted in IteM 19 . <br />T <br />P�nlgd/Typed Name i <br />// <br />signature l I s _ <br />r^ /i/ <br />l onth Da <br />l <br />DO NOT ITE BELOW HIS LINE.' - <br />(ellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br />lGeneratore who submit hazardous waste for transport out -of state, <br />DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />