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u uon.agency _ <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions On back Aoa9e b <br /> Please print or type. Form designed for use on elite(I2:=it writer. ' Deaartment of Toxic Subz:anc <br /> Socromento,C:ur•ornio <br /> LUNIFORM HAZARDOUS Generator's US EPA ID No. Manifest Document 2. Paget Information in the shaded areas <br /> WASTE MANIFEST <br /> s nor required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Address - _ - A. State, Document Number/Z f+A <br /> 2776 <br /> p ... _ _ _- - _ - >.I _• -_ - 3. State Generator's ID `� ^�`l <br /> 4, Generator's Phone <br /> (V 5. Transporter 1 Company Name6. US EPA ID Number C. State Transporters ID <br /> D. Transporters Phone <br /> -.r}rte i F ;'7—i-r.C.I <br /> C? 7. Transporter 2 Company Name <br /> P P Y 8. US EPA ID Number E. State Transporter's ID <br /> J I <br /> J I j I I I F. Transporters Phone <br /> V 9. Designated Facility Name and Site Address <br /> 9 H a <br /> _ 10. US EPA ID Number G. State Facility's ID <br /> H. Facility's Phone <br /> r 12. Containers 13. Total (� 14. Unit <br /> t< 11, US DOT Description(including PShioping N <br /> I No. Type Quantity Wt/Vol I. Waste Number <br /> Q escrroper Name,Hazard Class,and ID Number) <br /> Ci � - EPA Other <br /> _ _ Z._ I <br /> �o Eb. <br /> State <br /> m E <br /> vI <br /> R EPA/Other <br /> N II 1 <br /> v A <br /> O T ` SPA/01he, <br /> ci O <br /> R I I <br /> z <br /> L d. I I State <br /> Z <br /> W <br /> V I I I I I I I f EPA/Other <br /> U-1 <br /> `n I J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> CL <br /> V) ' BOTTOM WASTEf <br /> LU <br /> z G i i`ji TE c. d. <br /> J <br /> Q <br /> 0 Z I5. Special Handling Instructions and Additional Information I <br /> - - ----- <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,sacked, I <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> IF I am a large quantity generator,I cerhry that I have a program in place to reduce the volume and toxicity of <br /> dwaste generated to the degree I have determined to be economically <br /> a practicable and that I have selected the oracticable method or treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> v7 <br /> and the environment;OR, if I am a small quantity generator,I have made a good faith effort to minimae my waste generation and select the best•.+erste management method that is i <br /> available to me and that I can afford. <br /> 0} Printed/Typed Name Signature" Month Day Year <br /> Z <br /> w T 17 Transporter 1 Acknowledgement of Receictof Materials <br /> h Year <br /> w p Printed/Typed Name r,_, - I Signature _ __ Month :.cy <br /> P <br /> 0 18 Transoorter 2 Acknowledgement of Recei t of Materials <br /> RMonth Day Year I <br /> T I Printed/Typed Name Signature <br /> w E <br /> N R <br /> V19. Discrepancy Indication Space <br /> F <br /> Z� A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receiat or hazardous materials covered by this manifest exceor as noted in Item 19, <br /> T Printed/Typed Name Signature Month Dan, Year <br /> Y I I <br /> I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 3021A 14/97'. <br /> EPA 3710-22 <br />