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Mate O[l.allrarnia—Cnvii Vii.ntl�iiui ri�,a� v, <br /> Form Approved OMB No 2050-0039(Expires 9 301991 See Instructions on back otf~-•qe t5 Department of Toxic Substances Contra <br /> Please prim or type Form designed for use on elite(12 pitch) 4++er Sacramento California <br /> Y <br /> UNIFORM HAZARDOUS 1 t,enerator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> is rias required by Federal law <br /> WASTE MANIFEST + f' t` i` ) t aF <br /> 3 Generator s Name and Marling Address A State Manifest Document Number r,.w �y <br /> SttY1! Itx1 tl �i u>tns b5 0 <br /> 11 <br /> `.tis1 f+ll r i{ B State Generator's 1D <br /> 'O <br />' h 4 Generator s Phone I ) pay j ,t r V,tr <br /> CV 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter's ID[Reserved] <br /> 'n W <br /> 0 ^>t Ir 1 �f {r 1 - a"} a + i �+ D Transporter s Pha e y { (� 11 °�s <br /> O - �� �1 , i ' f .t i 1 1 r r <br /> F7 Transporter 2 Company Name 8 US EPA ID Number E Slate Transporter s1D[Reserved[ <br /> F Transporter s Phone <br /> V 9 Designated Facihw No a and Site Address 10 US EPA 1D Number G State Facility s ID <br /> i, ei., r irr Ssti i . ., r+ + 1 P @7 ♦'r is r+ i f. } 1 7 <br /> ,t r,r• �.Y iitt it s sRi H facility s Phone <br /> Q4 <br /> » O 1y <br /> W <br /> C."• Q 12 Containers 13 Tota[ 14 Unit <br /> q< 11 US DOT Description{including Proper Shipping Name Hazard Class and ID Number) No Type Quantity Wt/Val I Waste Number <br /> Z a State <br /> VAI � <br /> _ l oft, + i 14 t AI 1.�'i lt"lbt5' d t++' <br /> EFA/Other <br /> 3 G <br /> E State <br /> o N b <br /> 0 E EPA/Other <br /> v R <br /> A State <br /> C <br /> o T <br /> O EPA/Other <br /> R <br /> � d State <br /> Z EPA/Other <br /> LU <br /> lJ <br /> J Additional Descriptions for Matenals Listed Above K Handling Codes for Wastes Listed Above <br /> �.t }til♦ 11 .t 1Fi,li �, ii i.+i� b+,..i ♦iSit 7 p b <br /> !ter 7 <br /> V) c d <br /> oc <br /> ' Z 15 Special Handling Instructions and Additional Inlormation <br /> QA .,I 1'lr 1,41ld. ii 11 ht ride it„I I [tit +i 1}1'i <br /> Z 1 :+ t3 ' r x111 11 I i+ fit <br /> ' w <br /> S <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the consents of this constgnmeni are fully and accurately described above by propel shipping Home and are classified pocked <br /> Q marked and lobeled and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations <br /> V <br /> ' If I am a large quantity generator I certify that I have a program m 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 mode a good faith effort to minimize my waste generation and select the best waste monagement method that is <br /> available to me and that I con afford <br /> OPrinted/Typed Name J 77 ! Signature �f ? y l Y Month Day Year <br /> 1 Z <br /> w A 17 Tions orter 1 Acknowledgement of Receipt of Matenals <br /> Month Day Year <br /> WA Printed/TypediName +� 1 h •-^�� Signature t� �,��� I ' <br /> wS tij 1 Yw r1 i <br /> P <br /> fl - <br /> w 18 irons orter 2 Acknowled ement of Recei t of Matenals <br /> O i Prinled/Typed Name Signature t Month Day Year <br /> N E <br /> R <br /> ' L) 19 Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> L <br /> l 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted 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 />