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State of Colilomio—Environmental Protection Agency <br /> form Approved OMB No.2050-0039(Expires 9-30`96) See Instructions all back er 'a[�e b. Deportment o1 Toxic Substances Control <br /> #7 Sacramento,Califomio <br /> y Please print or type. Form designed for use on elite(12-pi %writer. <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS {r _ is not required by Federal law. <br /> Z"� of <br /> - - - - VITASTE MANIFEST . l ;i C3 i� Cy ,� , `j I 6 <br /> r -sap`J A ,Sfdte'M njfest Document Number '1 °8` ' <br /> i 3. Generator's Name and Mailing Address <br /> to _} _' n t r r %�4•`f`n f1 ` i z ;tlt r•'. ! - m �. a <br /> of f "• i e')V£ C \'t, ftry <br /> (� <br /> n r..n. L-)7:d r✓'?i.+�i ' 'e. : pm .tet ?re:: q - <br /> r�ft 4. Generator's Phoneb 1 t `tZ ^� -- t-rj` <br /> W . 'l l,. , <br /> O 5. Transporter-1 Company Name 6. US EPA ID Number C State Trsinsporter s lD :" 'r , <br /> 5 <br /> � <br /> 11 <br /> US EPA ID Number p 51r Transpoaels ID <br /> 7. Transporter 2 Company Name �.. <br /> Q _ x _ <br /> V f Trart;porterrs Phone <br /> Q 10. US EPA ID Number <br /> Address a 3, <br /> 4 9, Dfsignatet��F.aci�ity Nanleand Site <br /> I (.,,1 j Z f.. t y , <br /> $sem{' <br /> I. O j 5 ! 3T'i f-' 'j H Po6lity s Phone <br /> ;.f.� V Y _, 12. Containers 13. Total 14. Unit <br /> hhJJ including Proper Shipping Name,Hazard Class,and ID Number) Na T Quantity Wt/Vol F.:Waste Number <br /> Z <br /> I1. US DOT Description( 5t+z1y� <br /> Ep <br /> C'( E Stall <br /> a <br /> I n E EP¢JUther <br /> R <br /> o Astate <br /> 0 1 <br /> C.00 <br /> O EPA/OHter <br /> R <br /> f <br /> r <br /> Z d. M <br /> LU <br /> V EPA/,OTher <br /> LU <br /> 7— K:Handling Codes for Wcistes tisEed��Alsove <br /> s J -Ad dional Da ►non rMaFeng�Usted Above � � <br /> a. <br /> � <br /> OOOFM. <br /> C7Z� �to <br /> s° r <br /> O 15. <br /> t <br /> Spial Handling InstAru0ons and Additional Information <br /> t '� rW4 .vI� t -ta T <br /> -1 <br /> y <br /> Z3 �r ✓„i-,.,:'t it?;"t2.ilk-fdsr?✓' iF�,7:i�.��t �?"t :7� �!� •'t"' <br /> w <br /> 2 I <br /> J <br /> e contents of this consignment are fully and ording t y described above by proper shipping Home and are classified, <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that th <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 /> 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 /> economically practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> 44 threat to human health and the environment;OR,if 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 I can afford. Month Day Year <br /> 0 Prinfed/Typed Name Signature <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials a Month pay Year <br /> 0 A Printed/ pe _. Signature ��� /„ r.s <br />� Ty d Name., <br /> �. <br /> LU <br /> ::E P18. Trans p Aer 2 Acknowledge of Recei t of Materials Month Day Year <br /> R Printed/Typed Name Signature <br /> u. T <br /> O f <br /> R <br /> w <br /> to 19. Discrepancy Indication Space <br /> Q F <br /> V A <br /> Z C <br /> . — I <br /> t <br /> rials co <br /> 20. FacilityOwner or O rotor Certification of receipt of hazardous matevered b this manifest except as noted in Item 19. Month Day Year <br /> T Printed/Typed Name Signature <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DISC WITHIN 30 DAYS. <br /> DTSC•8022A (1/95) P.O- Bax 400. Sacramento, CA 95812-0400 <br /> 1 EPA 8700--22 <br />