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Form Approved OMB No 2050-0039(Expires 9 30 991 r See Instructions on back of j-"e 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on afire 112 pitch) 4f ter Sacramento California <br /> t <br /> UNIFORM HAZARDOUS 1-" Lnerator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST ,- t ', ]i t 1 is not required by Federal law <br /> of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number <br /> ' it { 4s N3 + rf+ -SFtc�S' i <br /> ) .i i I fi t`V Fzi.. L...3 y w -5�� + <br /> B State Generator s ID <br /> 4 Generators Phone [ ] f n J .r , ,r+r 7 <br /> �C4 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> LO <br /> M <br /> ," t' y D Transporter s Phone <br /> W <br /> _ y Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved <br /> ] <br /> t—' F Transporters Phone <br /> 'U 9 iDestgPate;l FoFdity garrletanA Stte?04i;efs 1 10 US EPA ID Number G State Facility s,jD <br /> H Facility s Phone <br /> = svl <br /> Q <br /> 11 US DOT Description(including Containers 13 Total 1 d Unit <br /> ?roper Shipping Nome Hazard Class and Ib Number) No Type Quant+ty WI/Vol I Waste Number <br /> _ a <br /> f State <br /> il't�.J+i st <br /> fi'ii' y? 1. *rtiJ 1,1 <br /> G Sr ' f ° I EPA/Other <br /> E b Sime <br /> N <br /> E <br /> a EPA/Other <br /> V A <br /> T ` <br /> State <br /> R EPA/Other <br /> LU d <br /> ' I-, y l ...,, State <br /> _r f <br /> EPA/Other <br /> w r r rl ! <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> �I yi.' `F • 1 f ')r J • t�r1'f i i' Tit! iii l.f: a b <br /> , <br /> C d <br /> J <br /> a <br /> 15 Special Handling Instructions and Additional Information , <br /> '4r sl I ;„fr ' c 141tbflf3 >,`141 11,141,tri i,fi 'it+,lt Jsu, • i'` ii 1 <br /> Z i it: ti J l,. ,> ] �F)t3 f` ' i14aq, i6' iF t11r tci <br /> U-1 <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 /> U marked and labeled and are m all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> if 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 economtcally <br /> practicable and that I hove selected the practicable method of treatment storage or disposal currently cvoilable to me which minimizes the present and future threat to human health <br /> and the environment OR if I am a small quantity generator f have made a goad 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 <br /> Printed/Typed <br /> Name Signature q �- r r - )Month Day Year <br /> k4 I-,;, <br /> r� �f ,.r r �� `J1 .. kf Z- <br /> t i <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials / <br /> LU p Pnnl{e�-d-/Typ=d Name r Signature r� r Month Day Year <br /> i S <br /> LI 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> r Pnnled/Typed Nome Signoture Month Day Year <br /> Q-) E <br /> Q R <br /> ' F 19 Discrepancy Indication Space <br /> A <br /> C <br /> 1 <br /> L <br /> l 20 Faclh Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year-71 <br /> 1 <br /> tDO NOT WRITE BELOW THIS LINE. ^ <br /> OTSC 8022A[1/99] <br /> 1A 8700-22 Yellow GENERATOR RETAINS <br />