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Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back r' 'age 6 Deportmunt of Toxic Substances Contrc <br /> Please print or type form designed for use on elite(12 pdc swrder Sacramento Coliformo <br /> ' UNIFORM HAZARDOUS I Generator s US EPA ID No Manifest Document No 2 Page 1 Information in rhe shaded areas <br /> WASTE MANIFEST i �_ , , a i `' f ,1, of is not required by Federal law <br /> may. } <br /> 3 Generators Name and Moil�ngAddresN A State Manifest Document Number <br /> 22970389 <br /> �.""� 7- . i` r Svl e� K ..�w �r+..,� (;; ���,�}' f 1 r , �}�.. p'e 'r'• <br /> _ B $fate Generator s 10 <br /> 4 Generators Phone f 1' Aj <br /> C"t 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter's ID[Reserved] <br /> LO <br /> 00 <br /> O D Transporter s Phone z r ♦ 1 s <br /> 7 Transporter 2 Company Nome 8 US EPA ID Number E State Transporter s ID]Reserved] <br /> s <br /> J <br /> VF Transporters Phone <br /> (R Designated Facility Name and 5,1e Address 10 US EPA ID Number G State Facility s ID <br /> Q r33�' 7 lic 71, .k'�3' <br /> A(,i .3 7,o , why i <br /> H Facility s Phone <br /> �' i. w rf t ^) _Y r ( /) �`{ a1 w �� �ft�t <br /> J <br /> VI 1 U5 DOT Description Imcludmg Proper Shipping Name Hazard Class and ID Numberl 12 Canfarnars 13 Tarot 14 Und <br /> No Type Quantity Wt/Yat I Waste Number <br /> Z a <br /> Srata q <br /> ~ a ='1 <br /> 3 G EPA/Other <br /> co N b 5rar. <br /> co E <br /> R EPA/Other <br /> v A <br /> U80 <br /> Tstate <br /> O <br /> R EPA/Other <br /> Of State <br /> z <br /> V EPA/Ocher <br /> LW <br /> V) J Additional Degrriplions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> t� 1�1c,SD' frti `k r'. <br /> a b <br /> IL <br /> 64 c d <br /> J <br /> Q <br /> Q15 Special Handling Inslruchons and Addstional Information T« z �,s/f �w Oyu y <br /> Ys J <br /> C) <br /> Z <br /> LU ?± _ <br /> J 16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of this consignment are Fully and uccurotely described above by proper shipping name and are classified packed <br /> V marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and not, <br /> government regulations <br /> IF I 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 /> Ice practicable and that Ihove selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human healthand 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 /> available to me and that I con afford <br /> O <br /> } Panted/Typed Name Signatures .�/� f - - Month, Day Year <br /> 4 r r� ,-. , ` �f ✓ <br /> t r <br /> T 17 Transporter 1 Acknowledgement of Receipt of Molenols <br /> w N Printed/Typed Name Signature Month Day Year <br /> S <br /> to P <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> B Printed/Typed Name Signature Month Day Year <br /> N E <br /> Q A <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> I. <br /> F 20 Focdil Owner or O erator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> T Printed/Typed Nam. Signature <br /> Month bay Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A(1/99) <br /> 'EPA 8700--22 Yellow GENERATOR RETAINS <br />