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Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back Of page 6- Department of Toxic Substances Control <br /> Please print or type form designed for use on efrte(12 prfchJ lypewrerer i Sacramento California <br /> ' UNIFORM HAZARDOUS <br /> 710onerclor's US EPA ID No Manifest Document No 2 +Page 1 information in the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST �' ) , at ; of <br /> $ Generator s Name and Mailing Address A Slate Manifest Document Number <br /> i „It <br /> t <br /> 23405913 <br /> B State Generators ID <br /> U)C4 Generator s Phone I I v <br /> 5 Transporter 1 Company Name 6 US EPA 1D Number C State Transporter s ID[Reserved] <br /> s <br /> � ' � D Transporter s PhonF 'S i <br /> W <br /> 7 Transporter 2 Company Name B US EPA ID Number E State Transporter's ID[Reserved] <br /> �Q F Transporter s Phone <br /> U 9 Desr <br /> gn4led¢aghty,74gmpiaricl S11e/jds](gfs tr _ 10 US EPA ID Number G State fpcdkty;IID Il 3. fT rr E r i f y <br /> `d <br /> ' 'i i t s` 0 r l H Facility s Phone <br /> Q I ill tieli t1', i re rs 1 i<s 1 (t fl j c>14 i7{(1-`fi I i <br /> y � J <br /> a 1 1 US DOT Description(including Proper Shipping Name Hozord Closs and ID Number) 12 Containers 13 Total €4 Unit <br /> ,V No Type Quantity Wt/Vol 1 Waste Number <br /> Z a T 11 i s " 1 f t 1r21ii lt`I L� 5�'�1°,{i >t ittr3 State <br /> H <br /> 3 G t l Y I t EPA/Other <br /> Nb State <br /> E <br /> R EPA/Other <br /> `Y A c State <br /> T <br /> 0 <br /> R EPA/other <br /> LU d State <br /> IFLLJ EPA/Other <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> a b <br /> e d es 4 <br /> J <br /> a a <br /> 15 Special Handling Instructions and Additional Information <br /> lttflriitl tw N ti i I ours to', ititnsc flol <br /> ie"t 9 ' r , If"t '5'11 tr t <br /> LU <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accuratelyy described above by proper shipping name and are classified packed, <br /> Vmarked and lobefed and are in all respects in proper condition for transport by highway according to opplrcable internationat and notional government regulations <br /> If I am a large quantaty generator I certify that I have a pro ram 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 hove selected the prachcabie method o 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 /> �y <br /> available to me and that I can afford <br /> Printed/Typed Nome� / Signature / r Month Day Year <br /> { <br /> R17 Transporter€Acknowledgement of Receipt of Materials <br /> WA Printed/Typed Nome Signature Month Day Year <br /> `L S I <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> N E <br /> a R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> 20 Fauh Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> j <br /> ] I H I I I I I <br /> 1 DO NOT WRITE BELOW THIS UNE <br /> DTSC 8022A 11/99) <br /> PA 8700-22 Yellow GENERATOR RETAINS <br /> d <br />