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Form Approved OMS No 2050-0039(Expires 9 30 99)-` See Instructions on ba I page b Department of Toxic Substances Conlr <br /> Please print or type Form designed for use on elite(1: }typewrifor Sacramento California <br /> t UNIFORM HAZARDOUS I Generator s US EPA ID No Momfest Document No 2 Page I Information in the shaded areas <br /> is not required by federal law <br /> WASTE MANIFEST �" _ r i i y,i s 4; ` �f s r 4' ^� of <br /> 3 Generator s Nome and Mailing Address A Stoll Manifest Document IJymlier <br /> � <br /> State Generator's FD <br /> 4 Generator s Phone (} �r ) +, 1 i ,�i S�+-:f CV Rese _5 Transporter 1 Company Name 6 US EPA ID Number C StaleTransporter's1DI1 <br /> 1 % <br /> 1 <br /> CO p�rsi <br /> O .r, f y i, ��,'`a ' �� Cr+ �j ,y.' ' '� �> � f i `f � �a�7�^Y er s P��-pr s � <br /> 3 5 <br /> 7 Transporter 2 Company Nome (Nr 8 US EPA ID Number £ State Transporter s ID <br /> �� If <br /> Q <br /> F Transporter's Phone <br /> V 9 Designated Facility Nome omit Site Address 10 US EPA ID Numbety G State Fat It s ID f ti <br /> Q _ 3+1 t rW r{ s 1 w s . : +^tr4C�i I F►t'Z *^ t� d i <br /> Z r e v( I _ vl t ( i k) l i lr, i 171 <br /> I I <br /> eL' rM H 'Facility <br /> ' Phone ft <br /> ` ,,. ri <br /> F33,t 'f ` <br /> > k <br /> C'r '.t� `-y �'+ ` 1 6 ' "h f 11 17 <br /> 12 Containers " 13 Total 14 Unit i } <br /> I I US DOT Description(including Proper Shipping Nome Hazard Gass and ID Number) I +r� <br /> No Type Quantity WI/Vol I, Waste Niji Aber <br /> a $tote,' <br /> r } + <br /> F rf ii x I <br /> ~ bdf t)S• �J i" Pti .4Y ��t"l �vie ir'�( -.! +: t'c.�✓i c3 1` i '�_S w i rtiI �!� 6 „t <br /> G Ep1'A/Geri ' r <br /> Nq b Stats <br /> y4 <br /> oma E 11 <br /> "T R EPA/OJfrer i <br /> C14 A <br /> o T t Slate + <br /> R EPA/Other ii <br /> s +s <br /> d. r <br /> d State <br /> z <br /> V EPA/other s i, <br /> LU ' f <br /> J Additional!Descriptions far Materials Listed Above + I f K Handling Codeg for Wastes Listed Above s, <br /> b'^< 1 t or <br /> i 7�i' i- � L.., � Sol <br /> tr C,x �I d <br /> t <br /> Q o F a e� a <br /> Z t e V S Y A4 <br /> 'O 15 Special Handling Instructions and Additional Information <br /> Q � V IL .' Jif yr2r r C Jj J <br /> Z <br /> LU <br /> 'F <br /> 16 GENERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed <br /> Q marked and labeled and ore in oil respects in proper condition for transport by highway according to applicable international and national 9overnmenl regulations <br /> V <br /> If I am a large quantity generator 1 certify that I have o program in place to reduce Ike volume and toxicity of waste generated to the degree I have determined to be economical) <br /> y <br /> practicable and that I have selected the practicable method of treatment storage or disposal currently avoilabie to me which minimizes the present and future threat to human health <br /> and the environment OR of I am a small quantity generator I have made a good froth effort Io minimize my waste generation and select the best waste management method that is <br /> a ovadable to me and that I can afford <br /> 0 <br /> >- Printed/Typed Name Signature f Month Day Year <br /> tAcknowledgement <br /> R 17 Trans orter 1 Acknowled ement of Receipt of Materials ' <br /> w A Printed/Typed Name/ 1 Signature Month Day Year <br /> N I '! F- / _ i l <br /> $ i — w F , 1_ , l d ' i I 7 / .� a' l / Fj r "4 L <br /> 0 18 Trans orter 2 AcknowledM ement of Recei t of Materials <br /> -T <br /> 0 A Printed/Typed Name Signature Month Day Year <br /> N E <br /> Q R <br /> F 19 Discrepancy indication Space <br /> A <br /> C <br /> I <br /> L <br /> f 20 Petits Owner or O erator Certihcahan of receipt of hazardous materials covered b this manifest except as nosed m Nem 19 <br /> T Printed/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A (1/99) <br /> ,EPA 8700-22 ' Yellow GENERATOR RETAINS <br /> r <br />