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Form Approved OMB No 2050-0039 f Expires 9430 991 <br /> See Instructions on back of page; f Department of Toxic Substances Control <br /> Please print or type Form designed For use on side(f 2 pitch)fypewrr►b, - Sacramento California <br /> UNIFORM HAZARDOUS I Generator s US EPA ID No Manifest Document No 2 Page 1 Information in Ike shaded areas <br /> WA5TE MANIFEST t �� i; , y is not required by Federal law <br /> of <br /> 3 Generator s Nome and Mailing Add'ress A State Manifest Document Number y� L'¢ <br /> 'S0 13 q 0 i19 <br /> t, I I, i 4 , it)1 B State Generator s ID <br /> 10 <br /> 4 Generator s phone I I ,Irl w t <br /> 'ttV 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID IReserved] <br /> r <br /> p <br /> 0 P ry F D Transporter s Phone eA � <br /> N , t <br /> C? � I <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved I <br /> J <br /> J F Trartsportar s Phone <br /> Q <br /> V 9 Dfsrgnoted FoceLt�r4l�larr ,yand Srite(Address 10 US EPA ID Number G Slate Facility SID 1 <br />'1QI- <br /> Z ti Wt , slit, I stiff <br /> a - H Facility s Phone <br /> 0 f c 11 ti [E :tip 1 tk e S 1 it. , ,ii t f f ,1 i1 i } I i f S it) *Z, ,0 <br /> LL <br />.r�J <br /> 12 Containers 13 Total 14 Unit <br /> V 11 US DOT Description(including Proper Shipping Nome Hozard Class and ID Number) No Type Quantity Wt/Vol I Waste Number <br /> La State <br /> 'Z <br /> T . I i I' + r'Et .K r1tii1 Y� til Ike +xl ! <br /> H <br /> 3 Ca EPA/Other <br /> i` 'R <br /> L E <br /> N b State <br /> 4v R EPA/Other <br /> A <br /> State <br /> O <br /> R EPA/Other <br /> d State <br /> EPA/Other <br /> LU <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> b <br /> C d <br /> J <br /> Q <br /> f5 Special Handling Instructions and Additional Information <br /> ' l 'l Y tl r. t o k i t l tri ti J ri i l x ss i�t r y <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of ih,s consignment are fully and accurately described above by proper shipping name and are classified packed <br /> marked and labeled and are in all respects in proper condition for transport by highway uccording to applicable international and national government regulations <br /> If 1 am a large quann 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 f have selected tke practicable method of treatment storage or disposal currently available to me which minimizes the present and future threal to human health <br /> and the environment OR If <br /> I am a smolt quantity generator I have mode a good faith effort to minimize my waste generation and select the best waste monogement method thin is <br /> °c avorloble to me and that I can afford <br /> O <br /> Prmted/Typed Name Signaturef _ r M/onth Day Year <br /> ..,. <br /> T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> w p Printed/Typed Name Signature Month Day Year <br /> P <br /> p 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> E <br /> Q R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> f 20 Facrlr Owner or operator Certification of receipt of hazardous materials covered b :his manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A 11/99) <br /> 1 P 8700-22 Yellow GENERATOR RETAINS <br />