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State of Collfornlo—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 3496) See Instructions on back of page 6 Deportment of Toxic Substances Contrc <br /> Please print or type Form designed for use on elite{)7prlch)typewriter Sacramento Coliforms <br /> 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS rs not required b Federal low <br /> WASTE MANIFEST 1 1 �' of y <br /> 3 Generator s Nome and Mailing Address A State Manifest Document Number_ �' <br /> r ;—,,I- <br /> d +� 1/Y' <br /> Le) <br /> II IYc( I I GI( 1) ' ;i 'i (_�l_i i t Fi ::1-1- - <br /> L State Generotors ID <br /> i" <br /> Co 4 Generator's Phone <br /> C3 5 Transporter 1 Company Name 6 US EPA ID Number i -4 C State Transporters 1D <br /> D Tr<msporter's Phone C � <br />' 7 Transporter 2 Company Name S US EPA ID Number E State Transporters ID y a au <br /> F Transporfex's Phone <br /> ZQ G Slate Foeelity s 1Do <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number <br /> H 1') ! H Facility's Phone ,. <br /> iii s( i r <br /> U <br /> 11 US DOT Description{including Proper Shipping Nome Hazard Class and ID Number) 12 Cortamers 13 Total 14 Unit <br /> Z No Type Ouant Wt/Vot I Wast <br /> e <br /> Number <br /> 1 7 <br /> 3 <br /> G t EPA/Other <br /> 1 " E 7 <br /> 0 00 N b State <br /> Co E <br /> v <br /> N R EPA/Other <br /> q <br /> ' m T c Stale <br /> O <br /> o, R EPA/Other <br /> LU <br /> Z d State <br /> Z <br /> w <br /> U EPA/Other <br /> W <br /> Z J Additional Descnptsons for Matersols Listed Above K Handling Codes for Wastes Listed Above, <br /> a 11b �4ega <br /> w3tT $� WN P <br /> It i 4k <br /> 1A'15 <br /> t �¢ <br /> 3a4 9 Y k <br /> 0 13 Special Handling insfruetions and Additional Information <br /> I <br /> 1 w <br /> 2 <br /> r <br /> 16 GENERATOR S CERTIFICATION I hereby declare that the contents of this consignment ore fully and accurately described above by proper shopping name and are classified <br /> Vpacked marked and labeled and are on all respects in proper condtion for transport by highway according to applicable international and national govemment regulations <br /> ' If I am a large quantity generator I certify that I have a program on place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> J <br /> d economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and Future <br /> e/y threat to human health and 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 <br /> a� waste mann ement method that is available to me and that I can afford <br /> ' O Printed/Typed Names Signature rMonth Day[ Year <br /> �r i "7 f�f.+ 4 1, i t �r l �°1 ! L f t ' " <br /> Z T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> W R <br /> (+� A Pnnted/Typed Name Signature �i /Jf ti Month Doy Year <br /> w s L I Iii 11 <br /> ty,t 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> O E <br /> ' R <br /> Vj 19 Discrepancy Indication Space <br /> U FA <br /> Z C <br /> 1 <br /> L <br /> I 20 Facd Owner or Operator Certification of receipt of hazardous materials covered by this montfest except os noted on Item 19 <br /> . T Printed/Typed Name Signature Month Day Year <br /> Y <br /> tDO NOT WRITE BELOW THIS LINE <br /> ' DTSC 8022A (1/95) Yellow GENERATOR RETAINS <br /> EPA 8700-22 <br />