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knia Flealth and Welfare AgencyDepartmenYofIth SeMcas <br /> OMBNo 2050-0039.(E)pfres9.90-91)' �/ See Insfte lons on baO�,�n'page 6. Toxic Substances Contra Program <br /> ype 'Fakrt yeslpned ler use on elite(12-pitch typewr to). Sacramento,California <br /> NIFORM"HAZARDOUS 1.Generators US EPA ID No. . �f Manliest Document.No. •21 Pope lt:,. Irformafkx1lrt the shaded areas <br /> WASTE MANIFEST 1 I 10 i 0 I O i 0 14 13 13 I4 11. 01 01 01 `T 1..l 1 cf y' In not requted by Federd-law. <br /> tt1 c nergtor:Na�ea ,Ma+kgAddre:s ,;KIK STOP �fAftKf:TS IfdCL nstare M�ce:tooevm.rn mj�er <br /> blT �650 ATTtd. tA#2. lIAC.0 fRIFFITF#) $stile <br /> • f <br /> ;E rsF,sore� �` 4567 ENTERPRISE <br /> < a <br /> a •r ti r ,., Number C Sfahe Ttarppdtfeys lD . <br /> FALCON ENEltS`l C.A. 0.918',-218,216 8 5, TQnsporteraP.tofe . <br /> S t fs y er 2 Company 8.US EPA ID Number I f Sithe Fans f f ID <br /> ' °• f' � :Y, I. f I I '� !� F Txiin SPtrotsts <br /> ' y TO. EPA ID Number - G S.fofe,£x sl[3 <br /> r y07 G%1� I , fad <br /> irys ,p• :rillL \� !��' H FoclNlys Phone:: ' <br /> 'i ; 12 Containers 1&Totd 14 Unit - - - <br /> 'Y'T jl.44SDOT D�plxmVirckding Roper Shippig Name.HcYad Ckm,and lD Numbed No. T Quant <br /> W/Vol .,F.Wastef <br /> SlOte <br /> rrl" E; `~ ,ftCRl4:HAZARDOUS' WASTE LIQUID <r <br /> 61 T1•` t <br /> NO <br /> MI/Q�Q Ar Wm <br /> ice <br /> �w Z. TIJ <br /> a ft t t I I I 1 I t I ati `b'ketb"� tits <br /> f'� *" e 1� �F _ � ....'.. � +c.. ... l Fj 4�� .a`n,• "s�iniE?!*� <br /> S i <br /> n <br /> nl <br /> or erksls Above <br /> t MyF� }$h„ � - FIaAa1 eCtA�v,B f �Y'.�•..4i,. <br /> I I I I I I <br /> tC IngCodesro>• mtesl.kt , <br /> } <br /> zifW r'< � - � WAiE,IL AfiiI1 Wk: : y<—r�r :.< <br /> C X. v <br /> ELM <br /> yr} <br /> 15�Sppepeial tlartdrinp Irctructbrn and Addrtbnal Ir(omxnron <br /> fr=a s24 HOUR 1WRGENCY PHONE.FALCON ENERGY„(800) 399-HELP Yst <br /> 'c "FAClI :132 3555 W,, HAMMER LANE. 'STM CA �t5209 . ., . <br /> Q 16..GENERATORS CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and arts classfied <br /> OPacked:marked,and labekM,and are Irjall-wspect6in proper condition for transport by highway according to appkable Internallond and.national government MgLi ti r S <br /> t ;F If I am a large qu arttity generator,1 cert that 1 have a program In place to reduce the volume and tax"of waste generated to the 1 ti's 7' <br /> fY decree I�fpve'determt>�a'o2�7 <br /> s' _economically practicable and that I have selected the.practicable method of treatment,storage,or disposal cumenty available to me which minimbm the pjetent acid llFlte +�'•'.. <br /> �}`�_uu threat to human health and the emkonment;OP.M I am a small quarltity generator,I have made a good faith effort to minimae m y waste generation andseleet <br /> r management method that is avaliable to rte and.thot I can afford. - <br /> +QQ' Prmted/ryped Name Signature - Montfl :.,Day <br /> ..ti.+r.+.�,w^'*,..•_.,,_,....:i <br /> ¢+7 sr I <br /> r a _• j z <br /> h T 17.Transporter 1 Acknowledgement of Receipt of Materials .•x <br /> C - R Printed/ryped Name - Signa ure, Month DoT 5 r Ty, •,.t <br /> S <br /> A wP t f. <br /> 0 18.Tram rter2 Acknowledgement of Receiptof Materials <br /> R Prin /Typed Nome nahue `* Month Y <br /> W -T <br /> ° <br /> 19.Discrepancy Indication space <br /> �Y 9. AILRA11 /�414xp vtvl4/rte' Cfa?J�/�e?`Jy�gr <br /> y <br /> C4, <br /> 7714e <br /> of vSr ,'r�j✓�N4� Y �Y , <br /> ,20.Fociiity Owner or Operator Certification of receipt or rdous materials red by" nfe except as rated in 19. <br /> T PMted/ryped me e - Month <br /> s Y t \`{. <br /> DO NOj WRITrVELOW. S LINE. t <br /> 1 •DHS8022A(1 <br /> Yellow:, TSDF SE THIS COPY TO GE*.RATCR��TFtW WDA ' <br /> + EPA8700--22 M *r»aiwrst•.. e <br />