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Form Approved OMB No 2050-0039[Expires 9 30 99) r` 1 See Instructions on back of -No G Department of Toxic Substances Control <br /> Please print or type Form designed For use on elite f 12 pttchj Titer i i Sacramento California <br />' 1,-.venerator s US EPA ID No Manifest Document No 2 Page I information to the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law <br /> WASTE MANIFEST ' <br /> i ;, t} rt } i ! 1 of <br /> 3 Generator is Nome and Mailing Addrgas A State Mani Fest Document Number �. q <br /> Iiti`1 t 41 .Siii.i Yr�l7t �, "+„��f FFV11 `1i If� <br /> i_6'l r,1; B Siole Generator s ID <br /> 4 Generators Phone I 1 tt'r <br /> t� <br /> 'N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reservedco <br /> ] <br /> O I "1 l ; "t `� J} ]r f i ' i,, 1 D Transporler s Phone <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> QF Transporter s Phone <br /> T� V 9 Dg}igpq#gd,fa4dlitx i�amgpr,F{$lie Addrg}s ,i, 10 US EPA ID Number G State Facd)ty$00 <br /> r z tlt,:r t 131 �, t;11 1i <br /> W H Facility s Phone <br /> Q Y. [f°e`•Yl,tt! 1 111 { -� ')#` 1" r It1 it it #i l i, I ( ( »til_situ '3'( f <br /> aL <br /> a12 Containers 13 Total 14 Unit <br /> V <br /> 11 US DOT Description[including Proper Shipping Name Hazard C€ass and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> State <br /> °; .#1 )tit lM1 ! YV.1 Yr .y+; r; [ SL <br /> 3 Ci 0 1, 1 1 EPA/Other <br /> i� <br /> l <br /> E b State <br /> O N <br /> om0 E EPA/Other <br /> v R 1 <br /> v A � s+me <br /> o T <br /> 000 O EPA/Other <br /> R <br /> LU d Siate <br /> "! t EPA/Ocher <br /> luZ <br /> t <br /> LU <br /> V) 1 Additional Descnpi ons for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> 1 '11tI1 �i . 1 �IISi l�l tiL e I{1 �z.r,':nt o b <br /> LU <br /> d <br /> J <br /> Q <br /> 15 Special Handling Instructions and Additional Information <br /> tltlttp W11, 11 F.ntiil('iri slat `tl,x1 ! f'{ .la i[r( a <br /> Z r t tl ..�. i �.; >•r S it [ V11f ] rs �liw� 1 ! li i nt11:"t e <br /> LU <br /> 16 GENERATOR'S CERTIFICATION t hereby declare that the contents of this consignment are fully and accurately described above by proper shippg name and are classified packed <br /> Vmarked and€oboled and are in all respects in proper condition for transport by highway according to applicable international and notsona€ginovernmeni regulations <br /> If I am a large quantagenerator I certify that I have a proyram 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 have selected the rotatable 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 smolt quantity generator I have made a good Faith effort to minimize my waste generation and select the best waste management method ihat is <br /> Q availoble to me and that I can afford <br /> Printed/Typed Name ! ! Signature �} " Month Day Year <br /> +I'rpt^ iy <br /> +� /F 3rY �- ,,. rr , ; , F s ! J <br /> T 17 Trans orter I Acknowledgement of Receipt of Materials <br /> ne A Printed/Typed Nam Signature Month Day Year <br /> S lr Y } [ r <br /> P <br /> � <br /> 18'Transporter 2 Acknowledgement of Receipt of Materials <br /> T Primed/Typed Name Signature Month Day Year <br /> LU E <br /> Q R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20 Focili Owner or O erator Certification of receipt of hazardous materials covered b this manifest exce las noted in Item 19 <br /> T Panted/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 />