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State of California—Environmental Protection Agency, <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back o' ge 6. Department of Toxic Substances Control <br /> Pl,ease print or type. Form designed for use on elite f72-pitch riter. Sacramento,California <br /> r 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST (y. a of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> C) - - l- B. State Generator's ID <br /> hA. Generator's Phone ( ) . ' `�t-+`.' ++{; ;'•��; _:,j.;:: <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved] <br /> In <br /> 0 '+ R1 m r� ,l•L ,tg D. Transporter's Phone <br /> o <br /> CP 7.7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> � Q F. Transporter's Phone <br /> V 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> H. Facility's Phone <br /> 41414141 R11 (909)424-1630 <br /> J <br /> 12. Containers 13. Total 14. Unit <br /> fw,•`�.,�U 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> a <br /> State <br /> ,'Yt`,, :l':h,7-.i�Ji;:h�1:,i�.` . 7i:• -J. a. _-, Li -! f,�t.;�-J!'.i '.{1 <br /> 3 Ci 0 1 D I ti/ . 0() ,,.!k,,,F5 EPA/Other <br /> 11 1 11111rsyt. <br /> C�4 Eb H <br /> State <br /> �� <br /> °CC) EPA/Other4 R oN, t � r ' yn[. <br /> qAc' State <br /> o T e: )� <br /> co 0 <br /> R -• I id s F t f +v EPA/Other <br /> f, <br /> LU <br /> d .. .t'!�`,fl" .._..1 s..t 1, _ot.r. '.;•::'h:�:f. .r ..r C+'. State <br /> 0. <br /> }'''y t }_ <br /> U v fi t L VA 0 t r f EPA/Other <br /> w <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z t-t fi <br /> 0 f 6tIP' MyyL��,,I4 },Tb. <br /> d <br /> .tt <br /> > <br /> (n • iyt ..a YI°1ar t e�•.' sr [ �f1Y1" ..t~`}U.:`�Y...3 <br /> F. <br /> � '• s.i5 t.:1'J.1J-. Ce'f-;::P. S+I'F��1:_ tN1':,r.; 1 1,Jtr,yFs`� �1 -'..... C. d. <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> r;. t ?: r,fr. rrs'• 4:.Jt::ut _ <br /> Z ^4 r "''- Ji4"4 ("s... ��' i t #' 'h� rl.�'CON f:;#"tvtfo�9r'Yif°'l"dto Se,,fwre ea, '!t'� _ 861 0) 475-3.@ <br /> -.. t <br /> t— <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,packed, <br /> Umarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> 2 If I am a large quantify 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 <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantify generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O <br /> } Printed/Typed Name' ! Signature 1 Month Day Year <br /> O t r <br /> Z �•t .j ! It ..� I f s. f„ <br /> w T 17. Transporter l Acknowledgement of Receipt of Materials <br /> LU A PrinVd/Typed Name —� a Signre Month Day121 s� Year <br /> R ! Al/ \ <br /> LU F f C s' rri i� pr.' fr i �! <br /> LL_ B 187 7 ans orter§Act no led a e`it of Recei't of aterials f �` <br /> R Printed/Typed Name �4 $i�nature I �_. Month Day Year <br /> LU RN <br /> V19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> I 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 80 (1/99) <br /> EPA 8700-0-22 Yellow: GENERATOR RETAINS <br />