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State of California—Environmental Protection Agency - I Form Approved OMB No.2050-0039(Expires 9-30-94) See Instructions on back o e 6. Department of Toxic Substances Control Please print or type. Form designed for use on elite(12pitch)Onter. Sacramento,California UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas is not required by federal law. WASTE MANIFEST Clar.,Vlolni 1159111,61 o 17 r1 of I 3. Generator's Name and Mailing Address A. State Manifest Document Number to Union Ice Co. t r [•t O, LU>; 108 ' '`n n n 014 a. btate Generator's ID n S$r.r irt,nr; fA 9'%20-1, f-i t:t,n I_xrrvy 141$1i5EnCr-fJ) l _r to 4. Generator's Phone i�,t� )7gfl - I -'..[ 6 5. Transporter 1 Company Nome 6. US EPA ID Number C. State Transporter's ID O 00 D. Transporter's Phone i'trl4grllt Inc. ii ( iii i. ri d i. _i � 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID Q I UIF. Transporter's Phone ! Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID + G)Z MIX 1142'1 "iAN,rA I-l. c?n- H. Facility's Phone NQ i�i I`JGI'IF11`J , F17. r',j 71 l:) ' 1.:, 21 11 t-: 51 1 (602) 1:,14 CD U 12. Containers 13. Total 14. Unit 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) Z NNo. Type QuantityWt/Vol I. Waste Number State ~ a. VQ, PO YCHL(04,l11A-ILC) DIPI-10-TILS, ", U11 ',:3:15, yllryl G 1 1 I ERG 3 1 v EPA/Other oo N b. State 00 E 4 R EPA/Other C4 v A oj C. State 00 T R EPA/Olher LU �- d Z State w V EPA/Other w N O J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above f'i_J:) i;t')hl l i ii 1,j 1.1611 Cv ')l"'!i[`l�-[ i;lt'li[=.f? <; 500 (4111 NLt; /!'q L.d. a- b. W J C. d. O 15. Special Handling Instructions and Additional Information ~ f)IJ-C C.If: Sf:CgV 1([-- 0A'[E: Oj t lit/94 Z A`:)I:I I C) SK IPJ CONTACT, WEA13 Pr-M f EC;T I'\)E. CL J H I I'03 �` �� C"y�+.,'i > �'�••L w 74 11R, �:htl_RGENCY P110N ' 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, .+ packed,marked,and labeled,and are in all respects in proper condition for transport b highway according to applicable federal,state and international laws. Q P P P P P Y 9 Y 9 PP' U If 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 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 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 W waste management method that is available to me and that I can afford. Q Printed/Typed Name Signature' ✓' f Mon Day Year )- l / r` Z r 17. Transporter 1 Ackn wled ement of Receipt of Materials ^ j lJJ R -. _.., ..�... A Print /Typed Name Signature ! l/ Month Day�7 .Year y LLJ P 0 18. Transporter 2 Acknowledgement of Receipt of Materials LU , Printed/Typed Name Signature; Month Day Year O Ft LU19. Discrepancy Indication Space U F A Z C I L I 20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. T Printed/Typed Name Signature Month Day Year Y DO NOT WRITE BELOW THIS LINE. DTSC 8022A (12/91) EPA 8700-22 Yellow: GENERATOR RETAINS