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State of Csalifornia—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-3099) <br />Please print or type. Form designed for use on afire f I2 -pitch, <br />See Instructions on back of le 6. <br />,rarer. <br />Department of Toxic Substonces Control <br />Sacramento, California <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow. GENERATOR RETAINS <br />EPA 8700-22 <br />1. Ge�t.r's�N.. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />• UNIFORM HAZARDOUS <br />- <br />Isnotation edby Federal law. <br />WASTE MANIFEST <br />I <br />of <br />3. Generator's Name and Mailing Address - -- <br />A. State Manifest Document Number �7 <br />j <br />23511 1 <br />_. <br />Generator's ID <br />:. _.._ .. .. <br />orator's Phone 1 7 - <br />A. Generator <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. Slate Transporter's ID [Reserved.] <br />D. Transporter's Phone , <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter', ID 1Re,erved.1 <br />F. Transporter', Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />-- - <br />H. Facility's Phone <br />12. Containers <br />13. Total <br />14. Unit <br />11. US DOT Description [including Proper Shipping Name, Hazard Class, and ID Number) <br />Quantity <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />State <br />EPA/Other <br />r j` <br />G <br />_ iJ <br />E <br />Slate <br />N <br />b <br />EPA/Other <br />E <br />R <br />A <br />Slate <br />T <br />C. <br />EPA/Other <br />O <br />R <br />d <br />state <br />EPA/Other <br />1. Additional Description, far Materiels Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />a. <br />Is. <br />i <br />d. <br />15 Special Handling Instructions and Additional Information. <br />c t_,1- .,_ •� .0 L. _::"gar. <br />i <br />16, GENERATOR'S CERTIFICATION: I bereby declare that the contents of this consiyrent are fully and accurate)y described above by proper shipping name orders classified!, Pecked, <br />labeled, in in condition for transport by highway according to applicable international and national government regulations. <br />marked, and and are all respects proper <br />'+ <br />IF I am a large quantity generator, I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to 6e ec.nomical)y <br />hove method of treatment, storage, or dispose[ currently available to me which minimizes the present and future threat to human health <br />practicable and that I selected the practicable <br />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 waste management method that is <br />and <br />waila6le to me and that I can afford. - - - <br />Printed/Typed Nama <br />Signature �' <br />Month Dai.-^ Year <br />U <br />/� <br />C•/ / tJ <br />V <br />s T <br />7 Transporter I Acknowled em rat of Receipt 1 M t rials. �- ""� �- -' --�+ <br />A <br />P nted/Typed Nome <br />Si re <br />MmDay, Year. <br />NS <br />- <br />S,, <br />D �l 7 <br />P <br />0 <br />I S. Transporter 2 Acknowl'ed smart of Recei t of Materials <br />TPrinted/Typed <br />Name <br />Signature Monts Day Year <br />E <br />R <br />j19. <br />Discrepancy Indication Space <br />F <br />= A <br />C <br />I <br />L <br />1 <br />20, Facility Owner or Operator Certification of receipt of hazardous materials <br />covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month DayYear <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow. GENERATOR RETAINS <br />EPA 8700-22 <br />