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'State of Ccdilornia--En.!to nml tai Protection Agency r �'I 1! Qb, I,. <br /> • Form Approved DMB IV OS�-0 9(L-pires 9-30.94) ,':: See Instructions on back Department of Tmtjc;Su6 tancrs Control <br /> Please print or type. designed for ase err elite(12-pilo x' Sacramento;Cc Tornio <br /> UNIFORM HAZARDOUS 1. <br /> rotor's US EPA tD No. Manifest Document No. P of thea shad areas <br /> WASTE MANIFEST r l rI P�' p v of is not req i d boddr f kTv. <br /> - 3. Generatc;6 I3ame and Mailing Address / / t s <br /> tfvl.rfFR ,S!� <br /> ;. 4. Generator's Phone.(�! <br /> (J L . <br /> 5. Transporter 1 Comdny Nome 6. US EPA ID Number ' <br /> _ �� >/tr�r1. StX.S•a�(�91c, Ojai o l 21 <br /> 7. transporter 2 Company Name 8- US EPA Ib Number <br /> ' Dosi>Tn Fatili ameand Site'',Add s I 10. US EPA,I�Q�Number r <br /> la 16V lit�) ri to5r So to Yl lr<}�'Sf <br /> tS } <br /> 11. US DOT Description(in Proper Shipping-Name,Hazard Class,and ID Number 12. Containers ^13- Total 14. Unit <br /> P { 9No. 7 Quantity Wt/Vol <br /> i#V a. �pp;;fi� Co u.sfl A# ; L��I4 id •C)•5. f <br /> '. x vd�lu J� vjx e 9 UN 1'71 6� (DCS <br /> Go N b. / <br /> , . <br /> ao Cur1'o5tl�e S� Faso Nd•5.��oc�t.�w. c�1'uhr e <br /> T c u�1 ��5do o #10 10 f <br /> P? o <br /> R <br /> d. „ <br /> n�V)i a �� <br /> 15. Special Handling Instructions and Add tionse Information r 1v6 pr /1� �12F� S>C6 ♦ _2 <br /> It , <br /> a'f J t K � f"C JJ1 17r l�U"'��fJ / � �-7 4-4-(11nr'rr �('1 <br /> 16. GENERATOR'$ CE(RTIFICATI014. I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping rwme and are classified, <br /> { packed,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 a program in place to rectum the volume and toxicity of waste generated to the degree I have determined to be <br /> L economically practicable and that t have selected the practicable method of treatment,storage,or disposal currently available to me which minimize the present and future <br /> threatto human health 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 <br /> waste monalEment method that is available to me and that I can afford. <br /> Ni led Typed Name S'gnature Month Day Year <br /> T 17; Transporter 1 Acknowledgement of Receipt of Materials <br /> A ' <br /> A Printed ed N me ,7 $igtsalvr ortt Dai - Year <br /> S <br /> 1'�(( � a2—K y a, <br /> 0 lb. Transporter 2 A knowled ement of Recei t of Materials ` <br /> ESiR '-Printed/Typed Nome <br /> gnature Month Day Year <br /> R <br /> . . 19. Discrepancy Indication Space .......-..._ <br /> ( F _ <br /> J A <br /> C <br /> 'i I , <br /> j t. <br /> 1 20. Facili Owner or Operator Certification of receipt of hazardous materials covered bthis manifest except as noted' Item 19. <br /> T PrintedJTyped No e l• Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> SC 9022A (9/93) {Generators who submit hazardous waste for transport out-of-state, <br /> PA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.} <br />