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Form Approved OMB No 2050-0039(Expires 9 30 991See Instructions on bock of page 6 Department of Toxic Substances Control <br /> Pleose print or type Form designed for use on elle 112 pitch)+ der Sacramento California <br /> UNIFORM HAZARDOUS I enerator s US EPA ID No Manifest Document No 2 Page 1 [Inormation in the shaded areas <br /> re uired b Federal law <br /> WASTE MANIFEST k i LL' I of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number <br /> 1 mitt tit t : +t b. +il <br /> iy 4 t + lil lr °ie i �r��� 0 V� � ti]_ <br /> its i+ f0 ,1 e +t „ B State Generators ID <br /> sn 4 Generator s Phone f 1 +t .` s t +, { <br /> 5 yTransporter 1 Company Name d US EPA ID Number C State Transporter s ID(Reserved] <br /> i r D Transporter's Phone00 <br /> *w 4ea <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> F Transporter s Phone <br /> V <br /> 9 �DesigAa]ad FacA11tX�Ngrggi3n�51]e Addrefs lig 10 US EPA ID Number G State Fauhy silD it <br /> + ky i 1if rr 1 t <br /> H Facility s Phone <br /> I It+ ll,r1ii it i t i l ai ii i = 1- '0- f],c iff1 ] <br /> +J <br />+, Q <br /> 12 Containers t3 Total 14 Unit <br /> 11 US DOT Description{including Proper Shipping Name Hazard Class and ID Number) <br /> No Type Quantity WI/Vol I Waste Number <br /> Stare <br /> aAt' l <br /> 3 [ r1 t EPA/Other <br /> E b State <br /> N <br /> E EPA/Other <br /> C14R <br /> v A c Slate <br /> 7 <br /> EPA/Other <br /> R <br /> wd State <br /> EPA/Other <br /> cn J Additional Descriptions for Materials Listed Above ell r K Handling Codes For Wastes Listed Above <br /> 6 <br /> c d <br /> 1 <br /> a <br /> 15 Special Handling Instructions and Additional Information <br /> esti'.,, l� t �T,'s L a�ttllii�,� i+ie l ii lie,`i�iiil,.� �l is tkSL 1 v ?� <br /> W <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shtppmg name and are classified packed <br /> marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and not, <br /> government regulations <br /> (J <br /> If I am a large quantay generator,I certify that I have o program in place to reduce the volume and toxicityof wase generated to the degree i have determined ra be aca amically <br /> practicable and that Ilselected the pra0co6le method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment OR if I am a small quantity generator I have mode o good faith effort to minimize my waste generation and select the best waste management method that is <br /> O available to me and that I can afford J <br /> Printed/Typed Name Signature 7 {8- Month r Day Year <br /> T 17 Transporter 1 Acknowledgement of Recei t of Materials <br /> W p Printed/Typed Name s Signature Month Day Year <br /> C $ <br /> P <br /> N18 Transporter 2 Acknowledgement of Receipt of Materials <br /> 7 <br /> T Panted/Typed Name Signature Month Day Year <br /> w E <br /> u7 R <br /> Q 19 Discrepancy 1ndicotion Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 20 Foci b Owner or Operator Certification of receipt of hazardous materials covered by this mamifest except as noted in Item 19 _ <br /> 7 Printed/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DiSC 8022A(1/99) Yellow GENERATOR RETAINS <br /> IPA 8700-22 <br />