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State oT California-Environmental Protection Agency
<br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back O' -rge 6. Department of Toxic Substances Control
<br /> Please print or type. Form designed for use on elite(12-pitch Triter.
<br /> CA
<br /> Yl 1 S Sacramento,California
<br /> 1. Generator's US EPA ID bio. Manifest DocnllN2. P 1 Information in the shaded areas
<br /> UNIFORM HAZARDOUS umeo. age is not required by Federal law.
<br /> WASTE MANIFEST1 C_ { � Cl �� tom.. ,� +� �� 1' e� �, -1 of {
<br /> 3 Generators Name and Mailing Address A. State Manifest Document Number
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<br /> B. State Generator's ID
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<br /> to A. Generator's Phone
<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C, State Transporter's ID[Reserved.]
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<br /> p 't i D. Transporter's Phone -
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<br /> _ 7 Transporter 2 Compc.�V Name 8. US EPA ID Number E. State Transporter's ID[Reserved]
<br /> F. Transporter's Phone
<br /> cou 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID
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<br /> //��� {•'i t, f?'e fi !, H. Facility's Phone,AG2ylifie "4ICAT101010161416q .fY7�tit1 VrpQ 12. Containers 13. Total 14. Unit
<br /> 11.. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste NumbeF
<br /> Z a• State
<br /> z I''1ort•fiialI.A, g,aiytarrouB Wade, Soiid 1,Y4'ayhrad',Sludge,
<br /> .G E CAL, EPA/Ot ��
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<br /> ao E EPA/Other,
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<br /> 4 00 O EPA/Other
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<br /> EPA/Other
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<br /> N J: Additicnd a tphonsfor Materials 1,sMyd Above�r� K Handling Codes for Wastes Listed Above
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<br /> tiP+a -.S ix a32lyi trYTB•c- {q`� ych - c. d.
<br /> O1i5. Special Handling Instructions and Additional Information
<br /> Q !iWaa Prop-ear, 4:.g4F3.F]l1..JIt' . EMERG—I17144°Y t.`ON"f'?XT VCT 015.975.7r_H 860 4.71-5479
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<br /> LU 41 1111t.5
<br /> 16. GENERAT.QR'S CERTIFICATION:_J,be e,y declare that the contents of this constgnment are fully an accurately described above by proper shipping name and are classified,packed, -
<br /> marked,and`Itlbefed,-vnd-en in all respects in proper condition far tf8nsport by highway according to applicable international and national government regulations,,
<br /> IF I am a largequantity generator,I certify that I hove'a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically
<br /> a practicable and that I have selected the ractica6 a method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
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<br /> and the environment;OR,if I 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 /> available to me and that I can afford.
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<br /> Printed/Typed ame Si at re ont Day Year
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<br /> LU T Ir Transporter l Acknowle emenf of rectiel of Materials
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<br /> w p Printed/Type ame 1. Signature /��, r
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<br /> U- .0 18. Trans otter 2 cknowfed ement of Receipt of MaterialsS"
<br /> 0 R Printed/Typed Name Signature Month Day Year
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<br /> (Qj 19:'Discrepancy Indication Space
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<br /> f^i. facility Owner or O erator Certificatjo of receipt of hazardous materiall covered by this manif st except as noted in Item 19. 11
<br /> T 'Piin d/T3p m y, Signature Monf Day r'',j or(
<br /> r �!,, ,: !"`_- l ✓ tills/�J
<br /> DO NOT WRITE BELOW THIS LINE.
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<br /> DTSC 8022A(1/99) Green: TRANSPORTER RETAINS'
<br /> EPA 8700-22 ,
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