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State of California—€nvironmentar,Protection Agency <br /> Form Approved OMB,No.2050-0699(Expires 9-30-99) See Instructions on back of ^"qe 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 N.,. 2. Page 1 Information in the shaded areas <br /> s not required by Federal law. <br /> WASTE MANIFEST rl r. j a of i <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> ..). >'012VV1y 21854292 <br /> r, Vr <br /> B. State Generator's ID <br /> Ln 4. Generator's Phone I ij�ti ) `b4{0—i1 j(.4 rt 1?hJ - ��_ -_._',s_s• < �1 r `i...r �`• <br /> N 5, Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> In <br /> C? D. Transporter's Phone() <br /> T' ! U] 371-5747 <br /> : <br /> O . 1 / ; � <br /> a? 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> ,♦V I F. Transporter's Phone <br /> 'J sr Q <br /> U 9. Designated Facility_Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> H. Facility's Phone <br /> O �jS ►::(i : J. ir,� 3 % _ _ 800-499-7145 <br /> J 12. Containers 13. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> �a . Type Quantity Wt/Vol I. Waste Number <br /> C114 V Z a.. State <br /> _ riff°�'1�� _ u:=s".`• ,SL.. _.. ;1 T', ..'J. ,.:. _;;!'> . . .- ?1u <br /> ~ I r)X)1.' �'J t•:�) .` y EPA/Other <br /> 3 G '� E f - 1)o01 <br /> o N b. State <br /> 00 <br /> 00 E <br /> R EPA/Other <br /> A C. State <br /> o T <br /> 080 O <br /> R EPA/Other <br /> LU d. <br /> State <br /> Z <br /> LU <br /> U EPA/Other <br /> LU <br /> N J. Additional Descripti s for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z i 1:3. Lr +� a. b. <br /> 0 <br /> N <br /> LU <br /> _ 1c. <br /> d. <br /> 0 15. Special Handling Instructions anted Additional Information <br /> Q �.ILh �i'ilr;v�:.J�.i'. vv•`•l.'_L.i: 916"37i--374" <br /> Z <br /> LU <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 011 respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J <br /> IFI <br /> am a large quantity generator,I certify that I have a program in plate to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currandy available to me which minimizes the present and future threat to human health <br /> N and the environment;OR, if I am a small quantity generator,1 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> ac available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature Month Day Year <br /> w T 17. Transporter 1 Ackno meriTof Receipt of Materials <br /> A Printed/Typed ed Signature Month Day Year <br /> LU yP '�� , f <br /> Sw 1' <br /> U B 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> LU E <br /> N R <br /> Q <br /> („) 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I <br /> I!! <br /> wner or O erator Certification of recei t of hazardous materials covered b this manifest exce t as noted in Item 19. <br /> j Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />