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Form Approved OMB No 2050-0039(Expires 9 30 991 , See Instructions on back of page 6 Department of Toxic Su6stances Control <br /> I'll so print or type Form designed for use on efrte f 12 pati- vaster Sacramento California <br /> UNIFORM HAZARDOUS generator s US EPA ID No <br /> Manifest Document 1 b 2 Poge 1 lnformat:on in the shaded areas <br /> u not required by federaflaw <br /> WASTE MANIFEST "'I'llif y; ! 1 of f <br /> 3 Generator s NameandMamlin$AddrosA f A State Manifest Document Number x1 is c ' *�y, <br /> ' w <br /> B State Generator's Ib <br /> %r) 4 Generators Phone (^ ai ) i'j kJ <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved I <br /> D Transporter s Phone p <br /> O <br /> s' t �� r+��r�� t � Eria ,3:, < <'�j l� iy, P (i1t.,) 371 +�f! <br /> W 7 Transporter 2 Company Name B US EPA ID Number E State Transporter s ID[Reserved[ <br /> F Transporter s Phone <br /> V 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s ID <br /> a Fc 5 '` f I}L � °`r' <br /> f r~ 4 f ,4 r�r: « y' ! 7 `e t F ;y H Facility s Phone <br /> ti <br /> ous{6) 37 l'"''E,rt�t <br /> J <br /> 12 Containers 13 Total td Unit <br /> yy Q 11 US DOT Description(including Proper Shipping Name Hazard Closs and ID Number) No Type Quantity Wt/vol I Waste Number <br /> a Staie <br /> ` r <br /> G r. 4 / %, ! 'J /w EPA/Other <br /> "s I <br /> E 6 State <br /> E <br /> R EPA/Other <br /> CN A c <br /> T State <br /> R EPA/Other <br /> CK, d State <br /> EPA/Other <br /> ua <br /> J Addi ional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> t Ls ZsI id1Iip � 4r ^' a b <br /> c d <br /> J <br /> a <br /> 15 Special Handling Instructions and Additional Informations <br /> r <br /> w <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this const nment are fully and accurately described above 6y pper shipping name and are classified packed <br /> V marked and lobeled and are in all respects in proper condition for transport by highway according to Opplicoble international andronational government regulations <br /> �r If I am a large quant%y generator I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be economically <br /> practicable and that I hove 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 l am a small quantity generator I have mode 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 /> Printed/Typed Name Signature Month Day Year <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> A Printed/Typed Name Signature Month Day Year <br /> w It , <br /> 5 <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> TR Printed/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 Facrli Owner or O orator Certification of recet t of hazardous motertaIs covered 6 this manifest except as noted in Item 19 <br /> Prmted/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> C 8022A(1/99) Yellow GENERATOR RETAINS <br /> s 8700-22 <br />