Laserfiche WebLink
_ State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-96) See Instructions on back page 6. Department of Toxic Substances Contrc <br /> Please print or type. Form design cl for use on elite(12pltyypewriter. 1a� Sacramento,Califonwo <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Inlormafion in the shaded areas <br /> UNIFORM HAZARDOUSC. is not required by Federal low. <br /> WASTE MANIFEST r } t;' t {ft I.LL _ of .r <br /> 3. Generator's Name and Mailing Address �T 3 ar F A She Manilas?Document Numbe95898212������! <br /> O his f?��yi i�ki7rjl/` i S C. �s)``1 �� /V- flirR ;ar <br /> nS �i ✓(�a« ` P.F t t B. State Generator's ID <br /> } �t y� <br /> Ln 4. Generator's Phone ( !�1) 1. /fr � R is <br /> C? �) <br /> 0 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID 6 l � <br /> cr `D. TrpnspotYer`a <br /> J <br /> 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporters <br /> Q <br /> U <br /> } �. F, Transporters Pharw <br /> Q G. State Facility's ID <br /> �s-•t Z 9. D�signatel Facitity Lame and Site Address 10. US EPA ID Number <br /> tY "7. <br /> H. Facility',Phone <br /> a -.jCYurtJit' ;•t.=t', (SID1.235-1393 <br /> CO U 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) No. T Quantity Wt/Vol 1. Waste Number <br /> 4.y_�4._t,;^- I .clefts trill: ;r;c� r - St° <br /> r j�) % Gi Cs ENi <br /> E a. ! <br /> m N b. Stare <br /> OD <br /> N E 'EPA/Other <br /> 4 A <br /> 6 State <br /> coo T c. <br /> O <br /> EPA/ <br /> R ' t]lltef• <br /> Uj <br /> Z d <br /> LU <br /> U EPA/Odw <br /> LU <br /> Z 'J. Adcitiona! rtphoas for Ahaieripls�Lrtecl Above Kr Handling Codes.ior Wastes listed.Abose <br /> OX Y t Tgn�C(S)#I�ir ' a. b. <br /> ,f -r ,"T�.'( ''l ham' rpt th. 5: ,. <br /> J lb .)r' Ice Ptpr 1000 :!Oft lfapatity: - t C. .. - d. <br /> Q <br /> 0 15. Special Handling Instructions and Additional Information <br /> h KE'ell-) r44Av fiom _ _:T �•j= _ .: }tc1 ~ ;, ?�ivJcZ ".i 'r�� s' f:.;:}I�lsdlc.t'.`` Vlf: 'C1 lCt',I c. <br /> Z i3.c, • -. . ?4 H3 �<+int- iJ�fn1 .CHL,Y-ppr'F 1ff';tt Te.­' Ids<7rt, QIVI� %s.3�. _3 <br /> LU <br /> 16. GENERATOR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping nome,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 /> a economically practicable and that I have selected the practi[able method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> rn 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 /> 0!: waste management method that is available to me and that I can afford. <br /> O Printed/Typed Nome Signature e,�, -V- Morrtlt Day Year <br /> ALIJ 17. Tr ns orter 1 A<knowled emmt of Receipt of Materials + <br /> (D A Prinfed)Typed Name �- Signa <br /> Nra ��r Month Day Year <br /> R jt r'- �+ �' fi'�f•M:.�' ? �"s+r � '' T��i ff i i �f �.l t.i _t; <br /> LU <br /> P <br /> W 0 18. Trans iter 2 Acknowledgement of Receipt of Materials <br /> P Printed/Typed Name Signature Month Day Year <br /> T <br /> O T <br /> a <br /> N19. Discrepancy Indication Space <br /> Q F <br /> U A <br /> Z C <br /> L <br /> I 20. Facil' Owner or Operator Certification of receipt of hazardous materials covered by this manilast except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> r Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A (1/95) To. P.O. Box 400, Sacramento, CA 95812-0400 <br /> EPA 8700--22 <br />