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ccurState of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-96) See Instructions on back of -qe 6. Department of Toxic Substances Contro <br /> Please print or type. Form designed for use on elite(12pikf 'iter. Sacramento,California <br /> UNIFORM HAZARDOUS .renerator's US EPA ID No. Manifest Document N— 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST =' w' t0 ? t ? 1 t snot required by Federal law, <br /> of <br /> fjsrygratet*ta Cj,c d,Mailing Address A. Sfote Manifest Document Number <br /> {. 217 {j E1E8EAVE <br /> STOCUON CA 95203-311,2 s_State Generafaes ID <br /> N ?09)148-?231 <br /> N <br /> A. Generator's Phone <br /> C? r <br /> 5. Transporter 1 Company Nome 6. US EPA ID Number C. State Trmnporter's ID 1 r •T - <br /> js f S <br /> D. Transporter's Phone <br /> Q7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID <br /> U <br /> _ F. Trrmsporfer's Phone <br /> t Z Fa t ppe q 10. US EPA ID Number G. State Focil' s ID- <br /> Cy <br /> CC O 3525.1 OLD SKYLINE ROAD: �If p t <br /> KE L LEPt� CIL a ! CA ' 323 7 C i 't H. Faciliy's Phone (209)386-9711 - <br /> < <br /> 209)386-97�s1 - <br /> u A fUU0646 i t <br /> w.. <br /> 11. US DOT Description(including Proper Shi m Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> w a./ Z P 9Shipping No. Type Quantity Wt/Vol .r.WosMrNinn6er s- , <br /> 'k/J a. ' r ••r - -• • •r , s .Stater <br /> 00 N State, <br /> 00 <br /> v E <br /> R <br /> EPA/ <br /> l <br /> o A rf <br /> 00 T c. State , <br /> O <br /> R EPA/Other. <br /> w <br /> F- <br /> Z d. state <br /> w <br /> U <br /> LU <br /> EPA/Ckher <br /> O A ftriW r61Tr Materials listed Above K. Handling Codes for Wastes Listed Above <br /> a <br /> a. b. 80 5" Q. b.. <br /> N <br /> w <br /> ac <br /> F d. <br /> Z <br /> ° <br /> a <br /> z <br /> LU <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, <br /> U packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> JIf I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> CL economically practicable and that I have sek-cted the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> V) 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 /> or waste management method that is available to me and that I can afford. <br /> OPrinted/Typed Name Signature..._ ��✓' Month D Year <br /> } ay <br /> U T`'� s- --/ L"f..�.. -y/.tea. <br /> Z <br /> R 17. Transporter I Acknowledgement of Receipt of Materials <br /> NPrinted/Typed Name `r'/. rl.. � 1` Signature-- �' ) I't h arch Day Year <br /> LLA 0 18. Trans rter?Acknowled ement of Receipt of Materials <br /> LL- T Printed/Typed Name' Signature Month Day Year <br /> O E <br /> R <br /> N19. Discrepancy Indication Space <br /> U U F <br /> A <br /> Z C <br /> I <br /> 1 <br /> 120. Facility Owner or Operator Certification of receipt of hazardous materia noted in Item 19. <br /> T Printed/Typed Name Sigi a Month Day Year <br /> Y <br /> - i <br /> DO NOT WRITE BELOW-JWS LINE. <br /> DTSC 8022A (1/95) - <br /> EPA 8700-22 ENVIRONMEN Yellow: GENERATOR RETAINS <br /> PERMIT/SERVICES <br />