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Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of-age 6 Department of Toxic Substances Contra <br /> Please print or type Form designed for use on efrte(12 pdchl yeter Sacramento California <br />' UNIFORM HAZARDOUS ,;i s US EPA ID No Manifest Document No 2 Page 1 I Information in the shaded areas <br /> i } s net required by Federal law <br /> WASTE MANIFEST of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number _` S <br /> r'ltii 1.�t ' i�•'t >a Jli.f d�j, P��1 <br /> .,t;,`L,t as 1, .al i r B State Generator s ID <br /> to 6 Generators Phone <br /> '(V 5 Transporter 1 Compony Name ry. 6 US EPA ID Number C State Transporter is ID[Reserved] <br /> D TrPrasp9rlgr's P{`C'" f <br /> y.P <br /> .( YI <br /> J <br /> W 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> J F Transporter a Phone <br /> J <br /> Q <br /> U 9 Designated Fcrti flfty No a and Site Address 10 US EPA ID Number G State Focility s ID <br /> 4�Q i i <br /> ss� ,i 5h 5,�1 rµiii ase sir 11 <br /> s1 <br /> ce I l ', ` i`'{' ^'4� H facility s Phone <br /> t 10 }tial' lir1 ii ryti.} R ] 11 !` t= 4� 1 c 1, 4t1 Also `��I R <br /> l <br /> r' V I f US DOT Description(including Proper Shipping Name Hazard Class and ID Number[ 12 Containers E3 Total 14 Unit <br /> No Type Quantity WI/Vol ! Waste Number <br /> Z a <br /> Staid <br /> 2 fi <br /> it s ' 1 11ct('1r1 if ,Y,i`sa, `iii Fal ti I t <br /> H <br /> I } EPA/Other <br /> ' E b State o N <br /> c5 E <br /> v R EPA/Other <br /> A c State <br /> o T <br /> m O <br /> R EPA/Other <br /> w d .State <br /> lF- <br /> Z <br /> It, <br /> u EPA/Other <br /> LU <br /> rA ! Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> 1" )tit 'r S ! f'd�sE ' t' tf t_rsr ,. ,a i ! if::.�`,? a b <br /> LU <br /> °C c d <br /> a <br /> 15 Special Handling Instructions and Additional Information <br /> to 4ty ,t! 014l11i s S ]. 8ttsw llC it �I'll', 41' of 41,11 so t ,til i <br /> Z l ata e V i,l r . lr ! ' till k f x s i °3 R it r <br /> LU <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 /> marked and labeled and are in all respects in proper condition for iron sport by highway according to applicable international and national government regulations <br /> If 1 am a large quenti. 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 have selected the practicable 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 made a 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 <br /> Pnnted,/T.yped Name Signature / �, -f Month Day Year <br /> C` ( 1 _ter Yr l'' t fJi'. Yr,yJ't/ <br /> R17 Transporter 1 Acknowledgement of Receipt of Materials <br /> U-11 Printed/Typed Name Signature Month Day Year <br /> P r <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> V) R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> I 20 fOCll Owner or O orator Certification of receipt of hazardous masenals covered b this manifest except as noted m Item 19 <br /> T Printed/Typed NameSignature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 8022A [l/99) <br /> PA 8700-22 Yellow GENERATOR RETAINS <br />