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` Seg aT California—Emvirenmerrtpl Protection Agency <br /> • Form Approred OMB No.2050-0039(Expires 9-30.941 lC See Instructions an back of, <br /> Please print.or type, Form designed for use on elite(72•phch)ryy..Mfer. ; Sacramenlp,Californ <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. P Infos on in a llryt�d are j <br /> UNIFORM HAZARDOUS `I � <br /> WASTE MANIFEST � � 1 . is r��mied�y Ila .� <br /> :Y <br /> 3. Generator's Name and Mailing Address <br /> A1 ,7 <br /> 4^ 4. Generator's'Phone ) / <br /> 5. Transporter 1 Company Name. 6. US EPA ID Number <br /> PO <br /> I�IAIZ I-W' tray/ DF t <br /> 7. Transporter 2 Company Name S. US EPA ID Number j <br /> U �� E <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> 10 <br /> r 11, US DOT Description(including Proper Shi 12. Containers 13. Total 14. Unit <br /> pt (' gShipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol <br /> Nt <br /> m N b. ( <br /> � J <br /> R t <br /> -0o U c <br /> r R <br /> d <br /> V II I <br /> Z 15. Special Handlings s'tructions and Additional Information ! i <br /> A </LO /Z <br /> =.v 16, GENERATOR'S CERTIFICATIONfrl hereby declare that the contents of this consignment are fully and accurately described above by proper.shipping name and are cfbssified, <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 /> i If I am a large quantity 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 <br /> aconomically practicable and that I have selected the practicable method of treatment,storage,or disposal currently availabl to me which minimizt� the present and future <br /> threat to hvmon health and the environment,OR, if I am a small quantity generator;1"ha e a gort to mi mize my waste genercition and select the:best <br /> r waste tnana ement method that is available to me and that I can afford. oa%effoj� <br /> ,r <br /> J Prints yped Name Sign tore Mnth Day ' Year <br /> o16 <br /> 17. Tr ns orkr 1 AcKnolZedgement of Reeei t o Materia <br /> Prince /Typed Name Signature Month Day ' Year II' <br /> r s <br /> $i <br /> u r P a Q __ .�...�- I. <br /> R2 AcKent of Recei of Materials - ' <br /> T Printed/Typed Name - Signature - Month Day Year f <br /> E <br /> 19. Discrepancy Indication Space (; <br /> d F <br /> .� A <br /> C <br /> y 1 1j <br /> 20. Focili Owner or Operator Certification of reMi t of hazardous materials covered 6 ihis-martifest except as noted in Item 19. <br /> ii <br /> r P f�Typed Name Signa}aFe`1 Month pay Year <br /> l` q <br /> dE <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENp5 THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> 37TSC 8022A (9/513) (Generators who submit hazardous waste for transport out-df-state, - <br /> EPA 8700:-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />