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State of Cakforma—Environmental Pr <br /> 9lection Agency <br /> Form Approved OB No 2050-00391(Expires 9.30.99) See Instructions on back of a 6. <br /> tttr Please pant or Hype form designed for use on elite(l2-pitchJ fy*PIA//iter. N"000Department of Toxic Substances Contr <br /> Sacramento,Colilo—o <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST a g ~l �j t'` ` is not required by Federal law <br /> , 1 <br /> 0 <br /> a" 3 Generator s Nome and Mailing Address <br /> l /1 vt 1(` ,�� L, _j•, <br /> •`l�� �n II {(yam){Ar �// t <br /> Q /' V 1 1 1 (.�'l ! 1 �.. 7 •fi r Q�� i <br /> enr n t n Generator's Phone II�l1��L� <br /> t\ �"l�.'��15�� � I Lr L.(<.�(.`.•� (.V`t- C� � Z I � � � ��;,�c �'. k s <br /> 5 Transporter I Company Nome 6. US EPA ID Numbererc <br /> m, <br /> O .. .., ,. _ .. .., _.... r ... u r.. r'� s r i� /'. r•. '7 ti Y ` ..Jaa<. cr rr: <br /> lL y1 t <br /> No m <br /> Tronsponer 2 Company Nome 8. US EPA ID Number R se'Atry <br /> 9 Des gnoted r t <br /> FQuhtName and Site Addres; 10. US EPA ID Number <br /> A s. <br /> t.cc: . : ..l�b'!1..).. <br /> tri Z I <br /> CG <br /> '• Tt�� 7�'? r <br /> Y .wt <br /> JV l;S DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) 12. Containers 13. 'Total 14, Unit `P�'t�h %.r -r <br /> No. Type Quantity Wt/Vol I� [q�¢Nuer <br /> �7 =1 fl h+.(`Td/� !I/s,!llf{T!(.>l.);t ,y/✓ `iii" 1 f[,7.f,if(l $tatetr <br /> 3 G ._ . , I TE,f'l�IQthet <br /> E <br /> �! N a <br /> ao E <br /> gFtFt f�•: <br /> o! T s 3 <br /> — R <br /> a <br /> Z 1 <br /> tarn Z '1.'AddiliangJ QPiSC' s4 `ti: 'r! {f <br /> w I •'r <br /> it �I 7 '� 7,X15'. � 'd .� ;'•��l°£ °r�C <br /> Z <br /> 5 Special Handling Instructions and Additional Information ff ^^ a <br /> �.' w� fid'%=:i-:L::i:hf�'•Y f+'rftJttl!�. •7(1�{-1:i+77-fin'a' <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,pocked, <br /> Q marked.and labeled,and ore in all respects in proper condition for transport by highway according to applicable international and notionol government regulations. <br /> Lll <br /> I <br /> !i I am a Iorge 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 economically <br /> o i practicable and that I hove selected the rrocticoble method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> end the environment;OR, if I a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O avails Lo m oAdxthat.i car fof (� �� <br /> am <br /> y i Pnnied/Typed Nome I I Signatufe Mon h py 1;i Ye9r <br /> Z I I •'- i 1 ! X1.1 11^ �- ' ( 1 <br /> `L 1 17 T"pisspoirterl Acknowled em M of Recei't of Materials <br /> r.r p 'r r,nte /Typed ome Signature r i�,•J/ .Mon -Do�� i• Yep( <br /> P <br /> i 0 19 Trans oner 2 Acknowled ement of Receipt of Materials <br /> O R Panted/Typed Name Signature Month Day Year <br /> w! <br /> r Q. R <br /> V 19 D�screponcy Indication Space <br /> F <br /> Z A <br /> C <br /> I <br /> L <br /> 1 20 Fac,hty Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Panted/Typed Nome Signature Month Day Year <br /> Y I <br /> DO NOT WRITE BELOW THIS LINE. <br /> r <br /> -5C 8022A (1/991 Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />