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Form Approved OMB No 2050-0039(Expires 9 30 99) a See Instructions on back of page 6,-—y Department of Toxic Substances Control <br /> Plapse punt or type Form designed for use on ebte(12 pdch)typewriter Sacramento CohFornia <br /> ' UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page I InFormahon in the shaded areas <br /> is not required by Federal low <br /> WASTE MANIFESTiti I1 !) �, ,� 1, 1, [ of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number ` <br /> "fi'{ed.li"�ti <br /> 1 f ,4"sti +t ,IA`it (�]i <br /> ,ht� <I, o t i ,i '1 1"1'), B State Generators ID <br /> LO 4 Generators Phone <br /> ' 5 Transporter 1 Company Name 6 US EPA!D Number C State Transporter is ID(Reserved I <br /> mto 7 <br /> i i} I i r n ! j f i x i �, D Transpgrler s Phone I' <br /> ap <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID(Reserved] <br /> J <br /> QF Transporter s Phone <br /> 9 D s+ nosed FaF111ty,Na a nd Site Address 10 US EPA ID Number G State Facility s ID <br /> h�Q � .. ...._i,t tet {• 1 i� !1 (i fl /i { r3 + i <br /> oc <br /> 10 <br /> H Facility s Phone <br /> t Eiji sY'1+5'+s lsi 4 r'i . ' Ott s € It it { <br /> tit 1, +,v)—1iF <br /> I I I I <br /> UI 1 US DOT Description lincluding Proper Shipping Name Hazard Class and ID Number( 12 Containers 13 Total 14 Unit <br /> No Type Quantity Wt/vol I Waste Number <br /> F u+>ll If State f>tI <br /> F <br /> G 1 1 I EPA/Other <br /> N <br /> E <br /> m N b State <br /> E <br /> �t R EPA/Other <br /> A <br /> T state <br /> O <br /> R EPA/Other <br /> a <br /> LU d <br /> State <br /> EPA/Other <br /> it <br /> J Additional Descriptions for Matenols Listed Above K Handling Codes for Wastes Listed Above <br /> a b <br /> J c d <br /> a <br /> 15 Special Handling Instructions and Additional Information <br /> 's1 r,Y V+i( YY ' f4�Ilcsiif V� it +i k t-hatill {1f tit Vf lit; <br /> LU <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately clescnbed 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 nohonal government regulations <br /> If I am a large quaatiry 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 I have selected the practicable method of treatment storage,or disposal currently available to me which mmimizes 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 /> 0 available to me and that I can afford <br /> Pried/Typed Namef/ f �r Signature / f�rn` y l Month Day Year <br /> A17 Transporter 1 Acknowledgement of Receipt of Materials <br /> LLu H Printed/Typed Name /> j �{' - Signature Month Day Year <br /> P - <br /> R1 B Trans oiler 2 Acknowled amens of Re[ei t o of Materials <br /> 1 Printed/Typed Name Signature Month Day Year <br /> w E <br /> L") R <br /> Q <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> 20 Faah Owner or O orator Certification of rete+ t of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day fYoor <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A(1/99) <br /> �PA 8700-22 Yellow GENERATOR RETAINS <br />