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Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of --eye 6 Department of Toxic Substances Contra} <br /> Please print or type Farm designed for use an elite 112 pstcht Mer Sacramento California <br /> s <br /> UNIFORM HAZARDOUS T"crenerotor s US EPA 0 No Manifest Document No'"' 2 Page I Information in the shaded areas <br /> WASTE MANIFEST s i ! 1 snot required by Federal law <br /> of <br /> 3 Generator s Name and Moiling Address A Slate Manifest Document Number 3 4 <br /> t lltt 1i*f t Wtn" ldfUli Yy <br /> iisl <br /> `11 it 1 fs,tt t 8 State Generator s ID <br /> 4 Generolors Phone <br />' tN 5 Trensporler 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> aO f f <br /> pt L ' D Transporter s Phone yy <br /> O 1 ff, � •l`r � r s, � � r � �� � t t< <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> QF Transporter s Phone <br /> f U 9 Djsigpated Fofllity garnpland Site,AgcIr�}s 10 US EPA ID Number G State Fgcil gflp <br /> 1 Z ( i Hl Wilts 1,tslit <br /> a+ H Facility s Phone <br /> Q ! i I([i il7.11l l ll� i ,'t it r 1s; v t tl IS l ti t ] ri{k i (i_tF"ii ] <br /> w <br /> Q 12 Containers 13 Total 14 Unit <br /> U 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type Ouantity Wt/Vol I Waste Number <br /> Z a <br /> z �i"i "s if tl r r.ii'ttn+a sR iia tit ItCI State <br /> ir1 1 <br /> r_ <br /> 3 G It t) t t l s EPA/Other <br /> N N b State <br /> 0 <br /> 00 <br /> coo E <br /> EPA/Ocher <br /> 4 R <br /> v A <br /> 'OTc stare <br /> aao O <br /> R EPA/Other <br /> Ljj d Stare <br /> w <br /> EPA/Other <br /> w <br /> ! Additional Descriptions For Materials Listed Above K Handling Codes for Wastes Listed Above <br /> b <br /> c d <br /> J <br /> a <br /> 15 Special Handling Instructions and Additional Information <br /> .i til !'( t]n`7 I tsiftttiF' ,'a rt�4111,1srl1]t!I' t4laiii,tfi] ! P <br /> Z ii it � . : ++i . r. '� t .aGS 1� litk 111 fryr t air, 1 <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 /> a marked,and labeled and are in all respects in proper condition for transport by highway according to applicable international and naironal government regulations <br /> U <br /> If 1 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 economically <br /> practicable and that I have selected the prociicoble method of treatment storage or disposal currently available to me which minimizes the present and future threat co human health <br /> and the environment,OR if I am a small quoncrty 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 /> i Printed/typed Nome n Signature Ff _ Monfh Day Year <br /> R� 4-1 <br /> Acknowledgement <br /> T 17 Trans orter 1 Acknowled ement of Recei t of Materials <br /> 11 Pnnteo/Typed Name ` Signature,' r��� Month Day Year <br /> LU M ^ <br /> Is <br /> 0 18 Trons orter 2 Acknowledgement of Receipt of Materials <br /> T Prmted/Typed Name Signature Month Day Year <br /> T <br /> V) E <br /> a R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> 1 20 Facile Owner or O erator Certification of rete+ t of hazardous materials covered b this manifest except as noted in Item 19 <br /> Panted/Typed Name Signature Month Day Year <br /> L r <br /> DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A ]1/99) <br /> �PA 8700-22 Yellow GENERATOR RETAINS <br />