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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of le 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch) rifer. Sacramento,California <br /> UNIFORM HAZARDOUS <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST _ l of , <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number t A 91 I <br /> +;C;IPA1Pr ,1 (jam{�,jj 1 <br /> -)55•,��.(S1 �. Al', 3TF.2'rai B. State Generator's ID <br /> to A. Generator's Phone (',;�0 ) Q/irS-1j��i�� ',—`� 1 �.-- _,,- . . t.•Tt �`a.,k�..._,.,� <br /> �.'. <br /> (V 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID(Reserved.] <br /> h <br /> ao <br /> O D. Transporter's Phone <br /> o Rfl:'il� ?t,;�lTktl"\r r. ..,: ;�N _r:.., •� � 1 , (216*; <br /> aD 7. Transporter ZCompany Name 8. US EPA ID Number E. State Transporter's ID(Reserved.]~ <br /> -J I I I I I I I I I 1 F. Transporter's Phone <br /> U <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> ,... <br /> �� 3t73'J �:A ± ._67;1 JT.;: :'" H. Facility's Phone <br /> E.EUN 13 A1023 <br /> J 12. Containers 13. Total) 14. Unit <br /> Q 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> U No. Type Quantity Wt/Vol I. Waste Number <br /> Z a. <br /> State <br /> G (r:i lir 9c ' [;L' G?( ';(t �- / EPA/Other <br /> N b. State <br /> o N ;tl !— �'_l . 'AZAIRT)US 'SAS"7, SOT-7:JOD <br /> , <br /> ao Rt- tnn EPA/Other <br /> C14 P 11 <br /> o T C. <br /> State <br /> co O <br /> R EPA/Other <br /> LU d. State <br /> t— <br /> Z <br /> w <br /> U EPA/Other <br /> LU <br /> V) J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Q <br /> b. <br /> LU <br /> C. d. <br /> J _ <br /> 0 15. Special Handling Instructions and Additional Information <br /> Q :4-tVli;tiC L'ZT.t'.II.�.:L83 Tle'-.1 ED ?:sD <br /> Z 4H^ °E=� :1C1 N AC : 916-371—_i;6,' <br /> L. t;CI <br /> w <br /> t— <br /> 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 /> Vmarked,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 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> d practicable and that I have selected the practicable method of treatment,storage,or dispo+af-m"ently 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 made a good faitk"effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature Month Day Year <br /> v <br /> Z ti t <br /> w R 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU A Printed/Typed Name Signature Month Day Year <br /> w P - <br /> u- 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> w E <br /> V) R <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> EPA 8700-22 Yellow: GENERATOR RETAINS <br />