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Form Approved OMB No 2050-0039(Expires 9 30 991 1 See Instructions on back of page,/ t department of Toxic Substances Control <br /> Please print or type Form designed for use an elle(12 pitch}typewrite, Sacramento,California <br /> UNIFORM HAZARDOUS <br /> 71Geneaior s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal law <br /> O {' t i of <br /> 3 Generator s Name and Moiling Address A State Mamlest Document Number ye t s <br /> i 11 It tilt s„iris , At, ,z r2. IVVV <br /> r 'z [ r't li t [ 4 i }71 't 3 <br /> "1,p ;I,tl, r ++z/}J 1 B State Generator's ID <br /> 4 Generator s Plane € <br /> 'N 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID Reserved) <br /> O s , D <br /> ✓ r, r r / 1 Transporter s Phone r/` �/'-� / �l" <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br />, <br /> QF Transporter's Phone <br /> .V 9 D i ted ac l N me and Site Addre s 10 US EPA ID Number G State Focdity s ID <br />" Q r t &44 ,I 'Z 1� r4, F i, rti I r1 <br /> L <br /> 1' Z 1 i,I tir rtl It I4. �+ i <br /> W H Facility s Phone <br /> t , 10 r+l til` ill s '% Lf' I' I it r , I> i +, } f �')13�+r(r 41LL- <br /> t [ <br /> Q 11 US DOT s V Description(including Proper Shipping Name Hazard Class and ID Number) 12 Containers 13 Total 14 Unit <br /> No Type Quantity Wt/Vol I Waste Number <br /> '= a sit is H s ,04 1 Slate r 1 ) <br /> H <br /> 3 rs f I1 1 c EPA/Other <br /> E <br /> N b State <br /> o <br /> co E <br /> -v R EPA/Ocher <br /> V A c State <br /> a T <br /> aao O <br /> R EPA/Other <br /> w d Siaie <br /> Z <br /> VL 1 ) EPA/Other <br /> ✓ 7r r <br /> LU <br /> J Additional Descriptions for Motenals Listed Above K Handling Codes for Wastes Listed Above <br /> Gss <br /> � c d <br /> Q <br /> 15 Special Handling Instructions and Additional Information <br /> V , r+iE�3Il1; 'r�3!'_it [1t'i1is1111t' V.01 <br /> Z i i „ , .,, .r, I I V14 1 1 t i I.i V c h f° ; <br /> LU <br /> U 16 GENERATOR'S 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 /> tail marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> If I am a large quantity generator I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be scene "'If <br /> y <br /> practicable and that I have selected the racticable 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 quantity generator I have mode a good faith effort to minimize my waste generation and select the best waste management method that is <br /> IV) <br /> 0 available to me and that I con afford <br /> -T <br /> r Printed/Typed Name Signature j Monil Day Yegr/ <br /> '� --It - y r�j 1 1( •cul 4J s� Y { i ' . ~d t� J� 'f cw t y� , <br /> R17 Transporter I Acknowledgement of Receipt of Materials <br /> LU LU A Printed/Typed Pierre Signature frMonth Dayr Year <br /> ,::Ew <br /> sL 0 78 Trans orter 2 Acknowledgement of Receipt of Materials <br /> R <br /> T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> vt R <br /> U19 Discrepancy indication Space <br /> �Z F <br /> A <br /> C <br /> Im <br /> L <br /> 20 Facile Owner or Operator Certification of receipt of hazardous materials covered b $his manifest except as noted in Item 19 <br /> T Printed/Typed Name Signature Month Day Year <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DISC 8022A ti/99) <br /> 'EPA 8700-22 Yellow GENERATOR RETAINS <br />