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u...._s a_e._sio�nHronmemal Protection AV--y- ,rel 1� C1 4' t`� N I 'k# �' 4' T ` P7 <br /> Form Apyre ad OMB No.2030-40D39(Expires .3096) �•. See Instructions on back of -9e6. Department or Toxic substances Control <br /> Hoof print or type. Form designed for use en ses(12,p")V"h. Sacrament,CaliforniaUNIFORM HAZARDOUS Is 1. GeMfaFo/s US EPA ID No. Manifest Documard . 2. Page 1 Information in the shaded areas <br /> -.{vi- - N not required by Federal law. <br /> WASTE MANIFEST A T� 1 1 z of <br /> 3. Generator's Nanta and Mail' Addrott <br /> In ZIE 1�1fkc Ru��c7s 'oaPoKnl)erJ ''. r �, <br /> 1 l ,A4� v Is,a 8011356 <br /> r .y <br /> TV(it:TZ,AJ eA 11�- 9510 S�. e�Gyeneratr's ID , <br /> <br /> <br /> S. TransparTransporter1 Company Name 6. US EPA ID Number i'$tole Transporter's ID <br /> 1 f,' e r+ I. p a<� I D. Transporter's Phone <br /> J <br /> 7. Transporter 2 Company Name 8. U EPA ID Number E. State Transporter's ID <br /> U <br /> A F. Transporle!sPhona <br /> Ln Q <br /> Z Dugnated Facility Name and Site Addrett 10. US EPA ID Number G. Sate Facility's ID <br /> OQ � t�'N�(LiiCgl 101e 1�14IA6Jk4C,"`r £ A -r10 <br /> I`') 35' 31 oW 5kyL,A1E 1Z1)- H. F.611"�'sPhone <br /> r1U 1I( Cr1Wnl on C L (i �v I y/ �� s ! (C c�t7 11 <br /> Z 11. US DOT Description(rods ding Proper Shipping Name,Hazard Clean,and ID Number) 12. Containers 13. Taal 14. Unit <br /> = ssNo. Type Quantity Wt/VolL;Wast.Number <br /> 3 c <br /> a E a5Z �U� 1-r i C: G I (? G t) a/otl er <br /> gg N Is. <br /> m <br /> r R A/cher <br /> oto A i, <br /> gD T a ,... <br /> oc <br /> Op U /N�-DJUsVE L EPA/Other <br /> R <br /> Zd. State <br /> W <br /> EPA/Other <br /> W <br /> Z <br /> i A IS F4 <br /> d. <br /> I _ <br /> Q 15. Special Halling InshucLons and Additional InlornsMion M Ei2LE ICY rru !`+9O0- H z`I - j b.'0 U W M <br /> f <br /> Z <br /> Z T Qn I <br /> Wplu ur c- A11 <br /> J V / / <br /> 16. GENERATOR'S CERTIFICAT N: I hereby d4clm dint the contents of this consignment are fully plind accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,and arc in all to proper condition for transport by highwpy according a applicable international and national govemmeM regulations. <br /> .r II 1 oro a large qua" generator, I certify thril I have a program in place to reduceJhe volume and toxicity of wase generated to the degree I have determined l0 6e <br /> a <br /> economically practicable and that I have selected the practicable method of tr ;storage,or disposal currently available a me which minimizes the present and future <br /> N threat to human heahh and the environment;OR,R Iesa a small quantity r, I hone mode�a good faith effort a minimize my wase generation and select the bell <br /> cc waste mann ement method Mat is available to me and thcW I"coh-aflorcl- <br /> Printed Typed Name March Day Year <br /> W 1 17. Transporter 1 A of Remi of Materials ' <br /> () A Printed <br /> /TYP"d Name ` Signohs l`1 Month l DaY ,Year <br /> W " \ C ( � - J <br /> 'c B _ S �. <br /> W 0 18. T 2 A entero of Ra«i of Aloteriah <br /> sl i Printed/Typed Name Sip A re Month Day Yam <br /> O t, <br /> uWj 19. Discrepancy Indication Space <br /> U P <br /> A <br /> Z C <br /> 1 <br /> 1 <br /> 20. Foch Owner or Operator Certification of receipt of hazardous materials covered by this manifest mcept as noted in Ram 19. <br /> T Priped/TypadNome ro Year <br /> Y — 7) <br /> DO NOT WRITE BELOW THIS UNE. <br /> F <br /> T FYellow: (SDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A 1/93) t� F�'q Generators who submit hazardous waste for transport outof-state, <br /> EPA e7t"1— produce completed copy of this copy and send to DTSC within 30 days.) <br /> STOCKTOR,CA <br /> MBH <br />