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State of Colifomia—Environmental Protection Agencyf. <br />- <br />Form Approved OMB No. 2050-0039 (Expires 9-30.96) See Instructions on back <br />-Please print or type. Form designed for use on elite (12-pA ) typewriter. <br />UNIFORM HAZARDOUSt. Generators US EPA ID No. Manifest Document No. <br />WASTE MANIFEST <br />AV)511 11 61311D 511 1 L-1 <br />3. Generator's Name and Mailing Address A' <br />kn <br />SToc.��o� UIJ+t IFS ScHvoc. D/S`1VC-T' <br />to <br />1944 U. E -L t-'rkj-4L VQ, CV1 Ct5':2 C5 a <br />t <br />Ln 4. Generator's Phone (� 9S3 -4 <br />0 5. Transporter 1 Company Name 6. US EPA ID Number C;� <br />age 6. Department of Toxic Substances Comm, <br />Sacramento, California <br />2. Page 1 Information in the shaded areas <br />is not required by Federal law. <br />cm of <br />OP <br />1 < <br />v <br />E <br />< <br />N <br />R <br />I <br />v <br />Printed/Typed Name <br />D TranspoS}ers PfiIL <br />o <br />A <br />o <br />T <br />C. <br />Q. <br />Transporter 2 Company Name -' <br />8. US -EPA ID Number ' <br />O <br />F State Transf octe rll) , <br />U <br />R <br />20. Facility Owner or Operator C <br />Printed/Typed Name <br />T <br />Q <br />Y <br />t— <br />Z <br />F. TraMporfcr's Ff o <br />LU <br />9. noted Facih'ty N m and Site Address <br />10. US EPA ID Number <br />C State Focnlit )D <br />IN255 <br />� <br />1CK;iGFi <br />Parr Blvd. <br />U) <br />Ffsaa <br />}2i�-hmxtdrl.w�i. 9�8G1 <br />% t <br />C. U G 0 9 4 6 <br />5 3 9 <br />i51C1�3--�-J3 <br />�a <br />U <br />_ <br />- <br />Z <br />11. US DOT Description (including Proper Shi m Name, Hazard <br />P (" gShipping <br />Class, and ID Number ) <br />12. Containers <br />No. <br />Tvoe <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />yp <br />L. Was Number <br />= a-N(�I—PCW-. iik-Lzan cm -is riaste. S� - <br />� 1 ick <br />3 G Wa to Fnl[nty 5�= tcra�Tank, <br /><ti E <br />000 N b. <br />ao <br />1 < <br />v <br />E <br />17. Trans orter 1 Acknowledge <br />N <br />R <br />P <br />R <br />T <br />E <br />v <br />Printed/Typed Name <br />o <br />A <br />o <br />T <br />C. <br />00 <br />Z <br />— <br />C <br />O <br />I <br />L <br />1 <br />R <br />20. Facility Owner or Operator C <br />Printed/Typed Name <br />T <br />LU <br />Y <br />t— <br />Z <br />d. <br />LU <br />U <br />w <br />U) <br />Z 'J. Additional Desc' tans far Materials Listed Above. <br />r', Fz y S r. �&` Tq k r 3�#f ` l C�J�+C,r <br />_ V) <br />Uj <br />Ivatve-b:en irie+ r to . With 15 <br />1Ls Dry Ice Per 1(100 Gallon aPaci.ty t c. d. <br />Z <br />O 15. Special Handling Instructions and Additional Information <br />a77vv.i;_y f:? orr, E lWaV_ S Wf?cil' }'lr:Irttiai' ohel1 <br />Z U.G.S.T. '.-,; 4 Fir. C<xntact t4a. �.v;.�.r � G.. ttc�t'iP. �� —tj <br />W <br />sta,512 <br />state. <br />EPA/Other <br />State <br />EPA/Other <br />State <br />i <br />EPA/Other <br />K. Handling Codes for Wastes Listed Above <br />a. I b. <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 />Q 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 />U <br />-� 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 <br />J <br />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 />h threat to human health and the environment; OR, 9 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br />waste management method that is available to me and that 1 can afford. _ <br />O Printed/ yped Name 1 Signature f t% ' / -} Month Day Year <br />} 1 L <br />U <br />1 < <br />ZT <br />w <br />A <br />N <br />17. Trans orter 1 Acknowledge <br />Printed/Typed.Nomo-- <br />f, ; <br />w0 <br />O <br />P <br />R <br />T <br />E <br />18. Trans onier 2 Acknowled em <br />Printed/Typed Name <br />R <br />19. Discrepancy Indication Space <br />tW <br />Q <br />U <br />FA <br />Z <br />— <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator C <br />Printed/Typed Name <br />T <br />Y <br />Signature <br />of Receiot of Materials - <br />Signature <br />of receipt of hazardous materials cow <br />Signature <br />DO NOT WRITE BELOW THIS LINE. <br />Month Day Year <br />_ I .- I --- I . <br />Month Day Year <br />Month Day Year <br />DTSC 8022A (1/95) Y'Anw: CcNrGF T ^ C L' - <br />EPA 8700-22 <br />