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Form Approved OMB No 2050-0039[Expires 9 30 99] See Instructions on back ofO e+ <br /> Please print or type Form designed For use on elrte 112 pitch)typewriter` P Department of Toxic Substances Contra <br /> ' Sacramento,California <br /> UNIFORM HAZARDOUS I Generator s US EPA ID No Mamfesl Documeni No 2 Page 1 Informaimn in the shaded areas <br /> WASTE MANIFEST (} ( j) I i ] r3 1 { is not required by Federal iaw <br /> OF <br /> 3 Generator s Nome and Mailing Add ss A State Manifest Document Number <br /> �grllF t10 <br /> ial C nrfw�uunri ,,� O „ <br /> loni <br /> in �rWLKI.014 t N b''t�O) B Slate Generator s ID <br /> 4 Generator's Phone ( ] 'p60 �),i 1 4 sr, 1 <br /> ------------------------------------- <br /> 5 Transporter 1 Compony Name _ 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> t 1 f ( r` "lr F1 t j D Transporter s Phone `t � Itf3 -y' <br /> _3 <br /> l <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s IP[Reserved) <br /> J <br /> J <br /> Q F Transporter s Phone <br /> tV <br /> 9 P91lgF4FI d.Fs°f1lNX q'"4,F sfjx�iRa Cdr 13 Fri` 10 US EPA ID Number G State r"IV d <br /> iLLZ J C tI ilii kvilln, f.<o'A <br /> 0 [ti ft]' llwi \ 1 911 H facility s Phone <br /> 559-1 <br /> 86-}11 <br /> n V 1 i US DOT Description(including Proper Shipping Name Hazard Class and ID Numbedritainers 13 Total 14 Und <br /> Type Quantity Wt/Vol 1 Wosta Number <br /> FK"} itV-rt 0Ws VVds1L ootlii StaleOIF- <br /> G 11 1 } EPA/Other <br /> E b <br /> N <br /> E Stare <br /> A EPA/Ocher <br /> T c Slate <br /> O <br /> R EPA/Other <br /> a <br /> LU <br /> d State <br /> r EPA/Other <br /> W <br /> J Additional Descriptions for Materials Listed Above <br /> K Handling Codes for Wailes Listed Above <br /> b <br /> a <br /> K <br /> 15 Special Handhng Instructions and Additional Information <br /> 1w'_ul !'1cigTci i ']crl)sl°Ifl Wttrrt 11,111LAA1lig l`rtOL'AtA f Will 400, <br /> tri F{ t.=r I'rii,.lrtr:ir f 1 "+()O 010Ir1/1 <br /> W <br /> 16 GENERATOR S CERTIFICATION I hereby declare that rhe contents of this consignment are fully and accurately described above by proper shipping name and are classified pocked <br /> V marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> J <br /> IF I am a large quanky generator I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical) <br /> Practicable and thot 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 I am a small quanSity generator I have made a good Faith effort to minimise my waste generalron and select the best waste management method that is <br /> O available to me and that I can afford A <br /> Printed/Typed Nome r I Signature j _ t r - --- -- Month Day Year <br /> TR 17 Transporter 1 Acknowledgement of Receipt of Materials + <br /> LU A Printed/Typed Name <br /> Signature <br /> H ! _ Month Day Year <br /> 0 18 Transporter 2 AcknowlecIctement of Receipt of Materials <br /> T Printed/Typed Name <br /> E Signature Month Day Year <br /> V) R <br /> Q <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> t <br /> L <br /> [ 20 Facility Owner or O erator Certification of feces pt of hazardous materials covered by this maniFest except as noted in hem 19 <br /> Printed/Typed Nome Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DISC 8022A (1/991 (Generators who submit hazardous waste for transporl out of stale <br /> A 8700-22 produce completed copy of this copy and send to DTSC within 30 days[ ` <br />