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form Approved OMB No 2050-0039[Expires 9 30 99) ,7 See Instructions on bock of ringe 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite f 12 pitch Iter f Sacramento California <br /> ? i <br /> UNIFORM HAZARDOUS h venerator s US EPA ID No Manifest Document No - 2 page 1 Information in the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST , r1 ,l 3 s 1 of <br /> 3 Generator s Name and Mailing Address A Stale Manifest Document Number a �„� <br /> ',ml 1. I t ollik t ala 1 E <br /> } � f�lll4t " 1 �il:Ef <br /> B State Generator s ID <br /> 4 Generator s Phone[ ) r ., t <br /> 'N 5 *Transporter f Company Name r 6 US EPA ID Number C State Transporter s ID[Reserved I <br /> co <br /> /�,rte R r '�r ;t �' it f� 3 � # �! ^/y D Transporter s Phone w��-R} J���y . /( /� <br /> I".1 i i/ '��/l( , I -, r /'M. F '` -7 ;J-6e- <br /> "n <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved} <br /> i� <br /> J <br /> J F Transporter s Phone <br /> Q <br />�.1 9 Desi a ecl uc h Nam n Site ddr s 10 US EPA ID Number G State FQcdisy y D <br /> gn S § [ +x Qp 9 i i� , I I <br /> Z lli 1t 3 fl IV lr),i J - <br /> 1 , I t I I 5 J r H Facility s Phone <br /> a l, t i,!t <br /> aL <br /> f•Q 12 Containers 13 Total 14 Unit <br />�M < 41 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> °, li 3 t, 5 1 ,t`.t,It t l� s1,1 is si 1'ts State 3 t! <br /> H t 3 <br /> 3 tr EPA/016er <br /> Nb State <br /> E EPA/Other <br /> r A , <br /> � T c 3 N r State <br /> O ^ <br /> R EPA/Other <br /> LU <br /> d '� - State <br /> EPA/Other <br /> w t <br /> +n 1 Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> ra! 1.,1 a b <br /> C d <br /> J <br /> 4 <br /> 15 Special Handling Instructions and Additional Information <br /> }" s i 4 I y, t f f f1l,lti �k 11. ii i lifli,IllLti` 'ti 171 it st k f i i s��4 S <br /> Z I t i i i„ , ., >1 � t f �0,0 <br /> f16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment ore fully and accurately described above by proper shippeng name and are classified packed <br /> Vmarked and labeled and are in all respects in proper condition for transport by highway according to applicable internotronal and nationa3 government regulations <br /> If I am a large quonii 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 economically <br /> practicable and that I hove selected the practicable method of treatment storage or disposal currently available to me whvch minimizes the present and future threat to human health <br /> and the environment OR IF I am a small quantity generator I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> 0 available to me and that I can afford <br /> Printed/Typed Name Signature/ i x/ Month Day Year <br /> ^ <br /> T 17 Transporter 1 Acknowled ement of Receipt of Materials i r, <br /> R <br /> PnnteclASyped Nome Signet ey s R Month Day Year <br /> ( +✓`f <br /> g ,6* <br /> n-'+'il"{i�'l 1� <br /> 0 18 Trans otter 2 Acknowledgement of Receipt of Materials <br /> IT I•nnied/Typed Name Signotu'rd' Month Day Year <br /> Uj E <br /> N R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 20 Facile Owner or n,,,^ r Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> PA$700-22 Yellow GENERATOR RETAINS <br />