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orm Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back of pa^ 5 Department of Toxic Substances Contra <br /> Please print or type Form designed for use on ehte I I2 pitch)typew _r Sacramento ColJornio <br /> ' UNIFORM HAZARDOUS I Generator s US EPA ID No Manifest Document No 2 page-F Information in the shad4al areas <br /> is nos required by Federal law <br /> WASTE MANIFEST ► ') '} {` i °, <br /> of <br /> 3 Generator s Nome and Mailing Address A Stale Manifest Document Number <br /> I S)l�tl u ' YI tJ tt 11llJ't +� F <br /> B State Generator s ID <br /> 4 Generators Phone{ ) t <br /> ' tCV 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> 00 <br /> �p t r ,t t ,F t•• ii �` r r t f if �} ti 1 p �2 D Transporter s Phone ;} <br /> j s4 / <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID(Reserved] <br /> t J <br /> Q F Transporter s Phone <br /> 9 .D4}igpoledrFaFilityName oft SiteAddrgss iii 10 US EPAfDNumber G State Foci lgys11D �r <br /> it <br /> » <br /> ' t t t 1<�'t ht4iti <br /> Q P fl7 iJt.L"i t )I 1!i11 H Fo[ilily s Phone <br /> i] ) <br /> Q 12 Containers 13 Total 14 Unit <br /> 4 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type Quantity WI/Vol I Waste Number <br /> = a ti tsi 1 ') t I;zrflt 1 tL'at t t ,sl, Slate tit <br /> ti <br /> 3 G it t' 3 I + L EPA/Other <br /> E <br /> O N b State <br /> co <br /> co E <br /> v R EPA/Other <br /> V A <br /> O T c State <br /> taco O <br /> R EPA/Other <br /> Zd State <br /> LU <br /> V EPA/Other <br /> F- <br /> Lu <br /> 1 Additional Descriptions for Materials listed Above K Handling Codes for Wastes Listed Above <br /> i'I till tl 4 %k I IL A- Atte Ill[ a b <br /> c d <br /> 15 Special Handling Instructions and Additional Information <br /> tA C ic! VI'ill' I 1 {,tE[f73)t 'N'i it, rl f f �t 'Or t <br /> z 1 i Fi t �t 1 r1 i n t r V11(1 t� ! 1 rfl>Y tit i 4 r. i t f <br /> rr <br /> LL <br /> 16 GENERATOR'S CERTIFICAT10N I hereby declare that the contents of this consignment are fully and accurately 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 nationol government regulations <br /> If I am a large quark fy 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 1 fsave 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 r i e t c / <br /> Pnntld/Typed Name 11 Signature1 ,._ Month Day Year <br /> [ s / <br /> T 17 Transporter 1 Acknowled ement of Receipt of Materials <br /> W R <br /> /y Printed nature/Typed Nome Si <br /> to R � g �'� Month Day Year <br /> Pvi �" �� � 1' JS t I 1 11 � 'y I f J � r } t � 5 �r <br /> 0 IS Transporter 2 Acknowledgement of Receipt of Materials <br /> RPrinted/Typed Name 5i nature <br /> 9 Month Day Year <br /> Q R <br /> E <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> jjj L20F��ralor Certification of recei t of hazardous materials covered b this manifest exce t os noted rn Item 19 <br /> Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A (1/99) <br /> 9P 8700-22 Yellow GENERATOR RETAINS <br />