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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of PV--r'�9f i Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch)typ ! Sacramento,California <br /> •i UNIFORM HAZARDOUS 1. Generolor's US EPA ID No. Manifest Document No.t I VIY.+Ldd604 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST A ( 5 (y S of <br /> 3. Generator's Name and Mailing Address - A. State Manifest Document Number 23639956 <br /> � �+ [� <br /> Trevor Pro[yy�-rt�er.pt�yr sa 2 3 6 3 9 9 5 6 <br /> 611P f<j rdPl I GJ". n b.benikq B. State Generator's ID <br /> o Su-,}kt-on, CA 0521s <br /> t^ A. Generator's Phone <br /> N 5. Transporter 1 Company ame j' 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> W) <br /> D. Transporter's Phone <br /> o .lean 4-iar4ors E tw Servlees IfTt <br /> � 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> Q <br /> �U 9. Designated Facility Name and Site Address a 10. US EPA ID Number G. State Facility'a b <br /> �d Cliesn Harbors San osre LLC - O 4 8 d 3 1 <br /> Vinti F•7Gf?';essn Roa+i H. Facility's Phone <br /> -.� WariJu;se•c:r ,9537 S, -_r 409 451-8000 <br /> 12. Containers 13. Total 14. Unit <br /> 11, US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type '.Quantity Wt/Vol I. Waste Number <br /> 4Z a. r C44 HAZAri)vU"S,NON DTT,REGUl..A-T`E—rul,INiA,fJ1,/FJt: 1.,� y State 331 <br /> 3 G ' `T 67 EPA/Other <br /> i <br /> E b Stale <br /> o N <br /> m E EPA/Other <br /> v R <br /> vA a -, State <br /> o T <br /> m O EPA/Other <br /> R <br /> w d. Stale <br /> H <br /> W EPA/Other <br /> U <br /> J. Additional Descriptions for Materials Listed Above f K. Handling Codes for Wastes Listed Above , <br /> Z I is.fLJ S1 ;' b'• <br /> O 1 <br /> N <br /> c <br /> � c. d. <br /> J <br /> Q <br /> Z15. Special Handling Instructions and Additional Information F.:F9Fcu' °Ji-'{FFi%7iV . F ;i i <br /> O V. ar KopecFFf?r#tn harxN]n rrastm i ia: iH3 { I:Nt) <br /> a <br /> z <br /> w - <br /> x <br /> r <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,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> 2 If I am a large quantity generator,I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economica11 <br /> d practicable and that have selected the practicable method of treatment,storage,or dispggGal currently available to me which minimizes the present and future threat to human health <br /> if I am a small quantity generator,I have made a oodifailh,'ff t to minimize my waste generation and select the best waste management method that is <br /> and the environment;OR, q ty g 9 <br /> at: available to me and thatI can afford. - ' <br /> If <br /> a ,PP..r'yynled/Typed Name Signpfyr/r''• +,; Month Day Year <br /> Z L��f"3�c Mcr E 1 . 1�er <br /> uu T 17 Transporter f Acknowledgement of Recei t of Materials j /1 <br /> WR $isnolufe Month Day Year <br /> u, p P i ted/Typed Nq�e 9 ✓� <br /> w s / h v� Irl Y� 1 `` `' <br /> LL D 18. Trans orter 2 Acknowled ement of RecbiEt.of MateRols ' <br /> RT Printed/Typed Name " Signature i Month Day Year <br /> w E <br /> V) R <br /> Q <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L s • <br /> 20. Facili Owner or Operator Certificbton of recei t of hazardous materials covered b this manifest exce t as noted in Item 19. <br /> T Printed/Typed Name , Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 . .. <br />