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State of California—€nvironmelttaotection Aganry <br /> Form Approved O1D1 o.205 Q(Expires 9-30-99) See Instructions On back O{ je 6. Department of Toxic Substances Control <br /> °''Phase print or type. ; arm dejign �,use on elite 17 2-pitch)typewriter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 1 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. .� <br /> WASTE MANIFEST is 7 nJ C 10 i]171511, j 51 41 1 n 1 of 1 <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> ' Yt , .. .i. `/ 42.�2 <br /> 553 rl'nL SLtI .:TjrmB. State Generators.ID <br /> O 95_Ly <br /> LO i4. GeneratorT�L " 3 - <br /> - <br /> ip <br /> n <br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State-Transporters ID[Reserved:],. <br /> ao 1 g, D. Transportets Ph'o <br /> o '-0<: .�/i;;;�;`"r.YTA?.. :i ,ZLST(ICVc C kjr) C 4 4 S:. a 5 r $e}' 37 47 <br /> O <br /> ao 7. Transporter 2 Company Name 8. US EPA ID Number E-. State Transporter s1D Reserved.]; <br /> Q Ft TransporterPh <br /> s one <br /> U Q� 10. US EPA ID Number G Stara 1t s <br /> 9Y,D.e 4t'"F•'�octf,� a,� te. C936c rt <br /> i�a rl���r Ll. 1( esUYiY. g�C.L <br /> �Z 3150 EAS"" PIC-' r`LXD. <br /> H. FactliTy's Phone• <br /> O LOS 00 t►NCi1.111::5, t:_4 P�3fi3 :: t� i3 Q ;J i3 5 Z G 59y7Ts <br /> 012. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Tye Quantity Wt/Vol I:Waste Number <br /> Nz ;a.. ar•...r� r t, . %ZI y r ^ttvD .v�rvt�S 3 VN-t)93 111 State. 1-14 <br /> DO,0 i) fl'-RC t�;]] '��1 w�t? r EPA/Other <br /> tiT ! ! �` (� Duk <br /> E b state <br /> o N <br /> oo E EPA/other <br /> 4R <br /> v A C Stara <br /> o T <br /> coo O EPA/Other. <br /> R <br /> ck� State <br /> LU d. <br /> w EPA/Other <br /> U <br /> LU <br /> Z J.Qd�fitional Descriptti+pns fpr Materials Listed Above K. Handling-Codes for Wastes Listed Above <br /> 11l r .7, r6 a. b. <br /> LU <br /> ac C. d: <br /> Z 15, S c�Q( rldl�ng 1W^'s ruc'y1gns qg p�drdiiQ q�lnForm♦off f5iont r� ni <br /> O '.t) iUi �ti ti.77))s� J¢.�. .fl�')��1.iYr :J �i�fUl)...F i <br /> Q 244..1 W'—I--'l.�T'L-NCC CGNTACTi: 1916-371--.5"74" <br /> Z <br /> w <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 /> Umarked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> —J+ IF I am a large quantity aenerator,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 economically <br /> Q- practicable and that I{rave selected the practicable method or treatment,storage,or disposal currentty 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,I have made a good faith effojt'fo minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. ?, <br /> OPrinted/Typed Name Signature Month Day Year, <br /> .. �� .. <br /> Z <br /> w T 17. Transporter 1 Ackn ement-of Receipt of Materials <br /> W p Printed/Typed tN-d-e/ ��,,,., --� ;,,, Signature --:r' Month Day Year, <br /> LLJ w <br /> U- 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 R Printed/Typed Name Signature Month Day Year <br /> w E T <br /> N R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> L <br /> 20. Focili Owner or Operator Certification of recei t of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/T .Name Signature Month ^Day Year <br /> DO NOT WRITE BE�6W,T IS LINE. <br /> DTSC 8022A (1/99) Green: TRANSPORTER RETAINS <br /> EPA 8700-22 <br />