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r <br /> State of Cofifomia—Ervironmerltal Protection Agency ! <br /> Form Approved OMB No.2050-0039(Expires 9-30-96) See Instructions on back ed ge 6- Department of Toxic Substances Contre <br /> Please print or type. Form designed for use on efire()2-pitchf typewrifer- Sacramento,California I <br /> k1. Generalor's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> 11 UNIFORM HAZARDOUS i5 not required 6y Federal law. <br /> WASTE MANIFEST <br /> of <br /> Ll <br /> f C w <br /> r 3. Generator's Name and Mailing Address v A:'State Manifest Docamiint Number'- `�•` <br /> 12 <br /> * B. State Generator's IO -. - <br /> ry <br /> W4- Generator's Phone <br /> O 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID - - <br /> R. Transporter's �l J , <br /> 3. <br /> Q7, Transporter 2 Company Name B. US EPA ID Number - E:,State Tronsporter's M - „ <br /> U <br /> F. Transporters Phone <br /> i Z 9. DeSignoted Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> H. Facility s Phone <br /> (5101235.-1393 <br /> �12. Containers 13. Total 14. Unit <br /> ,1 11. US DOT Description(including Proper Shipping Name, Hazard Gass,and ID Number} No T Ouantity Wt/Vol I�Wasta'Namber <br /> 'y }` <br /> 9'3' -i' - 1 •-li 1, I 5t.,J"lr HE �y <br /> wb. ; <br /> N00 <br /> _ <br /> State' <br /> :.._' <br /> N R I EPA/Other. ; <br /> 0 T c.Sfufe ` <br /> ao O <br /> R <br /> w <br /> 2: d. Stale <br /> V <br /> EPA/Other,, <br /> 1 <br /> !. Adrditional rtpttan�s^�f.�o�r.Matenals Lsted Abave,> s r- r r '`r c ry K£Handling Codes for Wastes Usted Above <br /> LU <br /> Tiis C t,5 �t J tk�e�Tt lriert A� w1t h"' <br /> lh� L?rY 1Tcf� Pi3Z 1000 Ga`11ar� :Ca acity. ' <br /> d , <br /> ° 15. Special Handling Instructions and Additional Information <br /> Z i ','? �., 'fly -r: � i`Ir3;lr t_ry4 )'�t' -!�'/- :.•�3T/ t�)i: �r'4'rl�1 �r i Y I�I -r <br /> Uj <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 /> { V <br /> ff 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 /> {#- 0- 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 /> V? threat to human heahh and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimae my waste generation and stied the best <br /> I waste management methad that is available to me and that I can afford. <br /> Printed/Typed Name Signature _ _ Month Day Year <br /> Z f 17. Transporter I Acknowledgement of Receipt of Materials <br /> w f <br /> (� A Printed/Typed Nome - Signature ,.r d. Month Day Year <br /> LU 0 18. Tronspofler 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> 0 T <br /> ° E <br /> R <br /> N19. Discrepancy Indication Space . <br /> < F <br /> V A <br /> Z C <br /> y I <br /> Jl L <br /> 1 20. Facil- Owner or Operator Certification of rete! i of hazardous materials covered by this manifest exce t as noted in Item 19. <br /> Il T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> F;',r�•. <br /> GE.NERA TOP FrJ;'S THIS COPY TO !]TSC WITHIN 30 DaYS. <br /> DTSC 8022A (1/951 P.O. £or. 400E 5ocromenro, CA 95812-0400 <br /> A EPA 8700-22 <br />