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Stare of California- Environmental Protection Agency y t <br /> See Instructions on back O9e 6. Depo invent of Toxic Substances Cont,,P. <br /> i <br /> Form Approved OMB No.2050-0039(Expires 9-9496) Sacramento.California <br /> Please print or type. Form designed/or use on elite(12-pitch)typewriter. <br /> 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 1 ,' of <br /> E <br /> Mpilin A. State Manifest Docuhient'Number <br /> 3. Gen-V<06 Nome ondl. 9 Address <br /> sn <br /> 1 <br /> u1 <br /> �• <br /> ' S. State Gerserafor s ID <br /> ii Y ,. -3. fi. 4 '41 <br /> LO 4- Generator's Phone ( ') - - <br /> co <br /> 6 5. Transporter 1 Company Name 6. US EPA ID Number C. $tate.Transporter's ID - <br /> p? D- Transporters Phone 2J-1393 <br /> J 7. Transporter 2 Company Name 8. US EPA 1D Number E Sfcrfe <br /> Q <br /> UF 7rartsportees Phone <br /> 9, Designated Facility Nome and Site Address 10. US EPA ID Number G State Faulity s,10 <br /> L 0 ;c ."1 H. Facility's Pfsone Aaa�d C <br /> 1' Q (_ _ -LL - �i38 .' <br /> •,lti <br /> .. U 12. Containers 13- Total IA. Unit - <br /> 1 i+ Z 11. US DOT Description(including PShipping NHazard Class <br /> ung roper ppng ame, a ,and 10 Number) <br /> No. T Quantity Wt/Vol 1. WasteNumber.; ;:n.. - <br /> r,3: a.14.) +'+l":1`i t-+ i.•�^ t4a: .. 'f State <br /> . <br /> -- G - I�YLi"�r".`• : ! --,•�.;r: _ ``y F l 0 <br /> tv + <br /> tJ00 <br /> b Pik;, x <br /> R EPA/Othier`CN <br /> :. <br /> o T c. State <br /> O EPA]Olhef I <br /> RV. <br /> u.t - <br /> to •r <br /> EPAJOA <br /> Z 3. Addtiphol Descnptions for Mntenals Listed Abore <br /> "K.'Handling Codes for Wastes listed Above 1§ P t <br /> 0I.A. D018) <br /> Il iu #s A � rz9 ? xp 9� <br /> "' r� Pero3eLun�HtiC12OC�s 20% <br /> P�+.e�ry &/�q, pp1! <br /> Q £w"101id 0% N4 '6 b 4 .•.Y- iv _, `� �' 7r t �' L @- C 4 t <br /> 0 15. Special Handling Instructions and Additional information <br /> 1' _ -iF wI-Cs[i Fll'.'=r I.:T�=i.1.^-•,i 1 i 1 r`_ __. <br /> I F <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicob$e internotional and notional government regulations. <br /> U <br /> If I am a large gaontiry generator, 1 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 economically practicable and that I have selected the practicable method of treatment, storage,or disposal currently ovoiloble to me which minimizes the present and future <br />? (n 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 /> s waste management method that is available to me and that I can afford- <br /> 0 nted/Typed Namq ,! U� .. /•.� ul Sigrsofu.e`.,J,�._ r!, r :fd i�✓, L_.7r(.:=,�v .. Month Day nYe0, .. <br /> Z F 17. Transporter 'Acknovileclemeni of Receipt of MaterialsLU <br /> ! ' <br /> Printed/Typed Nome -y Signature.' _ ("l } Month D Year <br /> 11 <br /> ti �' {1 <br /> LU 0 IS._Transporter 2 Acknowed ement of Receipt of Materials .t <br /> LL fl Printed/Typed Name Signature Morrth Day Year <br /> 0 t <br /> A <br /> N 19. Discrepancy Indication Spoce <br /> V F <br /> Q <br /> r A <br /> Z C <br /> I i1 <br /> j' 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 Signoture Month Day Year <br /> I r <br /> { DO NOT WRITE BELOW THIS LINE. <br /> 6ENFRATOR SENDS TH6 COPY TO DISC WITHW 30 DAYS. <br /> DTSC•8022A (1/95) i F.C. flux 400, Sac;urnenic, CA 95el2-0400 <br /> EPA 8700-22 <br />