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stale of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of -ige 6. Department of Toxic Sabsr miss Central <br />Ptease print or type. Form designed for use on elite f 12 -pito xritec , Sacramento, California <br />DO NOT WRI�E—BELOW THIS LINE.' <br />Yellow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DT5C 8022A (I/991 (Generators who submit hazardous waste for transport out-of-state, <br />produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />1. Generator's US EPA ID No. Manifesl Document No. <br />2, Page 1 <br />Information in the shaded areas <br />ORM HAZARDOUS <br />,. .. -.. : - -: <br />is. not required by Federal law, <br />'`" WASTE MANIFEST <br />of <br />3. Generator's Name and Moiling Address -. - <br />A, State Manifest Document Number <br />23499267 <br />B. State Generators ID <br />A. Generator's Phone ( -I ') --""" - <br />s <br />5. Transporter 1 Company Name 6. US EPA 10 Number <br />C. Stale Transporters ID [Reserved] <br />D. Transportar's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Re urv.drved.) <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address - 10. US EPA ID Number <br />G. State Facility's ID <br />- - <br />W Facility's Phan. <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number( <br />p (inc g per Aping <br />Containers <br />I3. Total <br />Quantity <br />I A. Unit <br />WI/Vol <br />I. Waste Number <br />No <br />No. <br />F Type <br />a <br />State <br />EPA/Other <br />G <br />- <br />Nb <br />Score <br />E <br />EPA/Other <br />R <br />c, <br />State <br />T <br />'O <br />EPA/Other <br />R <br />d <br />State <br />EPA/Ohm- <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes far Wastes <br />Listed Above N <br />b. <br />c. <br />d. <br />15. Special Handling Instructions and Additional Information <br />16, GENERATOR'S CERTIFICATION: I hereby declare that the contents of this wnsignmenl are fully and accurately described above by proper shipping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition For transport by highway according to opplicable international and national government regulations. <br />If I am a large quantity generator, I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to ba economically <br />practicable and that I h s selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and Future threat to human heallh <br />and the environment; OR, if I am a small quantity generator, I have made a goad Faith effort to minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Pg ted/Typed Name <br />Signal a /' <br />Mont „- ay v Years <br />T <br />17. Transporter 1 Acknowledgement of Receipt of .lariats <br />A, <br />P'nted/Typed Noma- <br />^Mont Day Y. <br />r <br />A <br />78. Transporter 2 Acknowled ement of Racal t of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />E <br />A. <br />_ <br />19. Discrepancy Indication Space f' <br />/ <br />F <br />C <br />1 <br />� � <br />L <br />[ <br />20. Facility Owner or Operator Certification of re ani t ohh.... does materials <br />covaredb-this manifest ex2e t as n ted iBHtem 19. <br />T <br />Printed/Typed N m ps 1" r1 <br />9gnatu7a'' <br />Month ` .Day Year. <br />DO NOT WRI�E—BELOW THIS LINE.' <br />Yellow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DT5C 8022A (I/991 (Generators who submit hazardous waste for transport out-of-state, <br />produce completed copy of this copy and send to DTSC within 30 days.) <br />EPA 8700-22 <br />