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Form Approved OMB No 2050-00391Expires 9 30 99) -+ See Instructions on bQCK of j-"e a Department OF Toxic Substances Control <br /> Please print or type Form designed for use on elite(12 p)tc `Titer r l Sacramento Ca#norma <br /> r <br /> UNIFORM HAZARDOUS1: -eneralor s US EPA ID No Manifest Document No+- 2 Page 1 Information to the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST o (t 11 '1 11 s of <br /> 3 Generator$Nome and Mailing Address A State Manifest Document Number N q <br /> 1 <br /> t 11 11 it s 1 t s t f�' !st t +I t 23405901 1�`rr��jj <br /> 8 State Generator slD <br /> eCVLn 4 Generators Phone I # <br /> 5 Transporter 1 Company Name b US EPA ID Number C Slate 7ransporter's ID[Reserved) <br /> to <br /> O ,/r �� Y �! w s" D Transporter sPhone <br /> 7 Transporter 2 Company Name l f 8 US EPA ID Number E State Transporter s tD[Reserved] <br /> '1 l F Transporter s Phone <br /> U <br /> 9 D stgnated FocillN Name and Site Address 10 US EPA ID Number G State Facility <br /> lrty s ID <br /> !, pit S tv fi !i n k ri 1 r <br /> Z it; -t t 1I1a1 o H Facility s Phone <br /> Ix <br /> O 1, rl' 1i+ Irr Its i `, t , , , 4 it it I ' r.0„1 �r;u4NI <br /> LL <br /> m 12 Containers 13 Total 14 Unit <br /> V 1 F US DOT Descr ption(including Proper Shipping Name Hazard Closs and ID Number) No Type Quantity Wi/Vol I Waste Number <br /> o State <br /> ,tit+li 1ti' / 1' +r,lirll 1L 1A 4714 t 14' <br /> r t I ' e f t l EPA/Other <br /> 3 G <br /> E State <br /> ' co N b <br /> 65 E EPA/Other <br /> v R <br /> V A c State <br /> o T <br /> o O EPA/Other <br /> R <br /> U <br /> d State <br /> EPA/Other <br /> LU <br /> LU <br /> rn J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> a 6 <br /> Uj C d <br /> J <br /> O15 Special Handling Instructions and Additional information <br /> H it L51i I }i r) a 1 f Ir']Hilt 1,t4 t+r 1 l 111 trjlii <br /> Z t I 11, r !,r iYr tl t S ift7 f 1 L lr sl\ +� ✓ f{ 1 I 1s 1 <br /> U! 16 GENERATOR S CERTIFICATION 1 hereby declare that the contents of chis consignment are fully and accurately described above by proper shipp mg name and are classified packed <br /> Q marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations <br /> V <br /> ' 1f 1 am a large quantaty generator 1 certify that I have a program m place to reduce the volume and toxsuty of waste generated to the degree I have determined to be economicallyy <br /> practicable and that I have selected the practicable method of Ireatment storage or disposal currently available to me which minimizes the present and future threat to human healtCL. h <br /> and the environment OR of I am a small quantity generator 1 have mode a good faith effort to minimize my waste generation and select the best waste management method that is <br /> Oavailable 10 me and that I can afford <br /> V �.•- :{= I”}i rf �1,gnolure</. Dpy Year <br /> Printtypfd Namgr —7— <br /> Z <br /> _" <br /> Zy <br /> T 17 Trans orler 1 Acknowled emenf of Receipt of Materials i <br /> Ur R Month Day jear— <br /> Ranted/Ty ed Name r, Signature f yr' } ;o � •'•? <br /> W <br /> S H �rY rrrp RA 1�1�1 ... f r <br /> O 0 1 Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> T <br /> Lu E <br /> R <br /> ' V 19 Discrepancy Indication Space <br /> f° <br /> A <br /> C <br /> I <br /> L <br /> I 20 facilityOwner or Operator Certification of receipt of hazardous materials covered by this maisifest exce i as Holed 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 />