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formApprr,edOMBNo.2050-0039(Expires9.30-88. Toxic Substances Control Division <br /> Please-' or type. (Form designed(or use on elite(: itch Lypewriter}. Sacramento,California <br /> UNIFORM HAZARDOUS generator's US EPA ID No. Manifest 2. Paga f Information in the shaded areas <br /> I' WASTE MANIFEST �� r , Document N r of <br /> is not required by Federal law. <br /> 3. Generator's Net a and Mailing Address A. State Manifest Document Number <br /> Iq <br /> ■�_s1 1 ' S. State Generator's ID <br /> 4, Generator's Phone( _ r T•� �rt�� ��� -��~J�'y <br /> �,. / w <br /> 0 5. Transporter 1 CogtPany Name ,� 6. US EPA ID Number C.—State Transporter's ID <br /> r %J . Transporler's Phonr } �; <br /> u� <br /> 7- Transporter 2 Company Name 6. US EPA ID Number E. State Transporter' fD .i <br /> OD <br /> f i" 3 , , f( ! f <br /> o �, f C F. Transp orter's Phon <br /> m 9. signated Facility Name and,Site Ad 10. US`E�PA ID Number G- State Facility's ID <br /> fC.•ftic+ "1 <br /> ¢ / acuity's Phone <br /> U f r"- � L 7 �� 7) <br /> �/ f <br /> Z - 12- Contain S 3 Total 14, f. <br /> 4 <br /> O 7 1. US DOT Description(Including Proper Shipping Name,Hazard Class,and M Number) Quantity Unit Waste No. <br /> ILL No. Type WtIVo, <br /> J <br /> ¢ a. I � ' ++ State <br /> Z GG <br /> E EPA101her <br /> N /, _ / j h <br /> E b. State <br /> N R <br /> o A <br /> m EPAlOiher f <br /> m T <br /> Q O <br /> v R C. State <br /> p h <br /> 0 EPA/Olhsr ' <br /> ¢ d. State <br /> W <br /> Z <br /> EPA1 Other <br /> C] <br /> V Cn J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z a. b. i <br />�}O <br /> C j <br /> J c. d. I <br /> a <br /> DZ <br /> 15, Special Handling Instructions and Additional Information , <br /> o¢ <br /> w <br /> z : <br /> J ' <br /> 16. <br /> U GENERATOR'S CERTIFICATION. I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified;'packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> -.1 international and national government regulations. <br /> N 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 <br /> ¢ determined to be economically practicable and that I have selected,the practicable method of treatment, storage, or disposal currently available Eo <br /> p me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a good I <br /> } faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. :i <br /> PrintLU <br /> Typ d Name f Signature _ r IYear <br /> l Month Day I, <br /> 7- T 17, Transporter 1 Acknowledgement cA Receipt of Materials <br /> iss R <br /> ILL L- <br /> A Printed/Typ d Name j Signature ! �`. Monts Day Year <br /> O <br /> 4,. r.-, <br /> nsponer 2 Acknowledgemen of Receipt of Matenala <br /> R Printed/Typed Name ` Signature ' .- Month tley 1 Yeac_. <br /> 5 y 4' I . <br /> U E i,' r ,i t G.. )i; i d <br /> Z 19. Discre ancy indication Space <br /> 1= i <br /> A <br /> C ` <br /> I <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this mani lest except as noted in Item 19. <br /> T PrimediTyped Name Signature Month Day pYear <br /> y <br /> DHS 8022 A(1187) INSTRUCTIONS ON THE BACK <br /> EPA 6700--22 YELLOW: GENERATOR RETAINS . <br /> (Rev.9-66) Previous editions are obsolete. <br /> k <br /> I <br />