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05/19/2005 THU 6:48 FAX 510 749 4150 NRC Environmental Svcs. 1a002/002 State of California—Environmental Protection Agency - , Form Approved OMB No.2050-0039(Expires 9-30.99) See Instructions on back of pc Department of Toxic Substances Control Please print or type. Form designed for use on elite(I2-pitch, rifer. Sacramento,California UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Poge 1 Information in the shaded areas WASTE MANIFEST /� �f is not required by Federal law. C L V/>V O Z 0 3 0 y 7 6 3 of I 3. Generator's Nome and Mailing Address A. State Manifest Document Number C4sT 4AY m0D 23452763 o P.O. aoX 2055,`Nr�tyS 70 rr7 A.8�!e�tar's Phba(ie�� 9 r a�� B. State Generator's ID r\ 5ro_ -1 2 TTS:t^' AtTt{T PK rSSO tJ N 5. Transporter I Company Name 6. US EPA ID Number C. Stale Transporter's ID[Reserved,) V) N 0 N R G EN✓XRONM EA17-4 L JERVZ'GES CAR Q Q 101111 D. Transporter's Phone re O 7. Transporter 2 Company Name 8. US EPA ID Number E Stale Transporter's ID[Reserved:) : F. Transporter's Phone Q U 9, Designated Facility Name and Site Address 10, US EPA ID Number G. State Facility's ID - ta CRCsSY � 0VC-Rr0Ai CALIJ-QJ2 1013 1401,1171 ?O 1630 V. j T O j7RC6T H. Facility's Phone I LOA)4R c�. cryn 11013C A 7 a 2 8 a q t q f56Z I-3Z-5445 f 12. Containers 13. Total 14. Unit I U 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and/IDD NNumber) No. Type Quantity Wt/Vol I. Waste Number NON- R02J1 HA2A1ZP00S WASTE, Y.L U(�I0 Stale 2� 3 G `VZL) 0!Q 11 7) ItA 0101011 0 EPA/Other, O N b' — State WE � R EPA/Other v A O T C. Stoie- 00 0 EPA/Other - R w d. Stole, t— w EPA/Olhar U LU N J Additional Descriptions for Materials Listed Above K. Handling Codes For Wastes Listed Above 0. ftA� 3 �$S1 k55� a b. N ce ce c. d. 0 15. Special Handling Instructions and Additional information 05C A PP RVP1?-T }TE PF9S01V q I- PPOTF-CT.TVE- E0UXPMCti17' Q Z 2q-4R F41E26CfJCY C0977417-T< rJ2G 6N✓j:201VffiCA -F}L (570)741- i3QO Uj S2TE: 0AMAQ0HF Pov/ER Ho(/SE .Tmt? 1.3170 PO % Zj 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,pocked, (Q7 marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations. J If'I am a large quantity generator,I certify that 1 have o progrom in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically o practicable and that I hove selected the raclicable method of treatment,storage,or disposal currently available to me which minimizer the present and future threat to Kumon heaHh and the environment;OR,if I am a smo I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me and that I<on afford. OPrint_ed/Typed Name Sig re Month Day Year Ue Z w C� T 17. Trans oder T Acknowledgement of Receipt of Materials L p Printed/Typed Name; Signolure Month Day Year � s / niTEL- F6 o w O 1 81015 LU P w 0 18, runs orter 2 Acknowledgement of Receipt of Materials 0 R Printed/Typed Nome Signature Month Day Year T LU E R V19, Discrepancy Indication Space Z F A C I L -- r2�O Focili Owner or Operator Certification of receipt of hazardous materials covered 6 this manifest except as noted in item 19. T ted/Typed Namo Signolure Month Day Year Y DO NOT WRITE BELOW THIS LINE. White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS, DTSC 8022A(1/99) To: P.O. Box 3000, Sacramento, CA 95812 EPA 8700-22