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Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page Deportment of Toxic Substances Control <br /> Please print or type form designed for use on elite f 12 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS I Generator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST ' + 1", <br /> 11 ly is not required by Federal law <br /> of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number <br /> cl tic t �y <br /> 23) 1 F(91 <br /> I yr <br /> B State Generator s ID <br /> in 4 Generator s Phone ( } �,u) U i 4i = .; <br /> C44 5 Transporter 1 Company Name 6 US EPA tD Number C State Transporter s ID[ReserveLO <br /> d J <br /> co <br /> l.ti iy r`}+d i i ,t� ' \ r) t t '.,� D Transporter s Phonejif 1 f f <br /> 7 Transporter 2 Company Name n 8 US EPA ID Number E State Transporter s ID[Reserved) <br /> Q I I I I I I I I I I IF Transporter s Phone <br /> V 9 hDesig,nojedrEagIttf+FYontelagd Sile Andress 10 US EPA fD Number G Slate€pufty"IID +S r3 it •i I t+ ! 1 <br /> d <br /> r. +1 ',f `Q Ohio• strl,li; <br /> tY H Facility s Phone <br /> O f ,IIit.It i+!' iii 1, til f �i' t t i, t s! l l7 sS = i-:,, tT [ <br /> it <br /> 12 Containers 13 Total 14 Unit <br /> V 11 US DOT Description(including Proper Shipping Name Hazard Closs and ID Numbed No Type Quantity Wt/Vol I Waste Number <br /> S �°, „ c s i+l r.11sli si s ' rcy"l , + 1 State + <br /> d1}1 <br /> t- <br /> 3 Ci f+ «i ,•w f (r 1 EPA/Other <br /> E <br /> 'o b N stare <br /> coOE <br /> 4 R EPA/Other <br /> CN A <br /> 'o T ` <br /> State <br /> ado O <br /> R EPA/Other <br /> ccd <br /> Stare <br /> lZ <br /> LU <br /> u S ! } l t EPA/Other <br /> LU <br /> J Additional Descnp+tons For Materials Listed Above - ItK Handling Codes for Wastes Listed Above <br /> 6 <br /> LU <br /> c d <br /> a <br /> PQ 15 Special Handling Instructions and Additional Information <br /> ++t t,l f'rt tk t h f4k111,114J �%fieri I I ti)! f)l1r4> i I tit (id <br /> Z t I ";t I ! t'^ + I v+vt t i t t ui s kiln r! <br /> ua <br /> S <br /> t— <br /> Q 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipp ing name and are classified packed <br /> 11 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 /> V <br /> If I am o large quanliTy 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 economicallypracticable and that I have selected the�rachmble method of treatment storage or disposal currently available to me which minimizes the present and Future threat to human health and the environment OR if 1 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 /> +z available to me and that I can afford <br /> O <br /> Printed/Typed Name T Signature / / r_- Month Day Year <br /> R17 Transporter 1 Acknowledgement of Receipt of Materials <br /> LQ A Printed/Typed Namo Signature Month Day Year <br /> M <br /> o P l t+ <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> LLJ E <br /> rn A <br /> 19 Discrepancy Indication Space <br /> A <br /> C <br /> L <br /> 20 Facile Owner or O erator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> T Pnnied/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 />