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State o Coldortxa--Enhronmental Protection A <br /> Form kpproved OMB No 2050-0039(Ei�rce V30%) See Instructions on back of page ft! rtmenr of Toxic Substances Control <br /> Please print or type Form designed for use on a&re(12pikh)typewriter 1S 011 Sacramento California <br /> UNIFORM HAZARDOUS 1 Generators US EPA ID No Manifest Document No 2 Pogo 1 Information in the shaded areas <br /> 613 <br /> WASTE MANIFEST fVl , L r/ f J �� f 1 .4 <br /> is not required by Federal law <br /> 3 Generator's Name d May Address T A <br /> in on <br /> 4 Generator's Phe ( <br /> 5 Transporter 1 Company Name b US EPA ID Number <br /> a0 <br /> a <br /> 7 Transporter 2 Company Name 8 US EPA ID Number <br /> U <br /> Z 9 De nated Facd N and Site Address 10 US EPA ID Number <br /> a :7C1 CKSOe't'rr <br /> 4'00 '595 Ptrr Blvd - <br /> a €,.ic-hm-xid CA, 94301 C A D 0 (s 13 4 f ; 3 3 2 1^tA,N <br /> 11 US-DOT Description(including Proper Shipping Name Hazard Class and iD Number) 12 Containers 13 Total 14 Unrt <br /> t/Z No Type Quantity Wt/Vol <br /> a`tsM-i?C7rZfiararr_trAAz Waste Solid <br /> 3 <br /> O16E Wa--t F i11'rL `_to &qe �.rarkjC 7 1 I� Z1101010 <br /> P� N b .i <br /> v E <br /> N R <br /> C4 <br /> d A <br /> 00 T c <br /> O <br /> aC R <br /> W <br /> ~ <br /> Z d <br /> LU r <br /> V � <br /> J Adftpnot.DeK ria A0 K, Handling Codes foc Wast"UsW Abovq <br /> LU _..� ��.�- -Tank(s) have beM IfteiAth-15 <br /> lbaDry Ice Per 1000 G&11M qty. � . t c <br /> Z b <br /> O 15 Special Handling Instrucirons and Additional Informa�on ` <br /> t— flCti`�� c'1[b't11 i�3-OrI1 sour CC"a' -Y` igni t 'on P-17,o-1 rS w, -ar hleTr7R lat-s when al:-w,KI <br /> l C. i w g j it .s11! [ Ic�i71t- tY 'f <br /> LU 1 <br /> LA Nj <br /> Tc�'1`� <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping norne and are classified <br /> Q packed marked and labeled and are in all respects to proper Eonddtan for transport by highway according to applicable mternationof and national government regulations <br /> U <br /> JIf 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 practicable method of treatment storage or disposal currently available to me which minimizes the present and future <br /> N threat to human health and the environment OR of I am a small quantity generator I have made a good foAh effort to minimize my waste generation and select the best <br /> p:. waste management method that is available to me and that I can afford - <br /> 0 PnMed/Typed Name Signature _ Mond Dory Yea <br /> y 7 � <br /> Z N 17 Tran iter 1 Acknowledgement of Receipt of Materials <br /> LU N Printed Typed Name [( Si 1 i' Month Day Year <br /> LU <br /> iy 0 18 Titer 2 Ack6owledgement of Receipt of Materials <br /> LL. T Pnnted/Typed Name Signature Month Day Year <br /> O A -c, � <br /> N19 Discrepancy Indication Space <br /> Q F <br /> U A <br /> Z C <br /> I <br /> L <br /> I 20 Facile Chvner or rotor Cerhficatton 01 racer of hazardous materials covered Hits manifest exce as noted m Item 19 <br /> T Pnrrfed/Typed Nome Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC 8022A (1/95) (Generators who submit hazardous waste for,tronsport out-ofstate <br /> EPA 8700-22 r i k produce completed copy of this copy and send to DTSC within 30 days) <br /> i� <br /> f <br />