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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 nage 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 112-pits writer. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST L _ is not required by federal law. <br /> 'f <br /> 3. Generator's Name and Mailing Addres / f ri�l� ( A. State Manifest Document Number �+ <br /> 2 2 5 9 9 5 4 <br /> B. State Generator's ID <br /> 104. Generator's Phone (?�)_ - ` 6 -/7�� �'' �( Zo �' <br /> N <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tronsporier's ID(R s ry .] <br /> V) <br /> OP WF.i GREIN XNV:LIbAHItf>d AL D. Transporter's Phone <br /> o <br /> —44{� <br /> 00 7. Trans orter 2 Com any Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> � l Ilnl� rTKA IM10MVI ON & <br /> VQ I21tt' M ASI ICA, INC_ F. Transporter's Phone 408/,FWO447 <br /> ui6 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> Mc 21 rr cl�remulzy, 1CM] <br /> �/�/�� 2N5 NRUI.,A 141f) DRIVE Rk"I � H. Facility's Phone 1 <br /> L/0 VKRN lis) , SSV 89408 1 N1 V .I. :� ti t' <br /> CIA 12. Containers 13. Total 14. Unit <br /> 04611. US DOT Description(including Proper,Sphipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> Z ��� r Z i ./ �J State 7 <br /> 3 G � �' 7Xf�.eJs f L n 11 EPA�t}r., <br /> O r L rJ �/ <br /> NE b. ✓ State <br /> o N <br /> co <br /> coo E EPA/Other <br /> v R <br /> cV <br /> v A c State <br /> o T <br /> act O EPA/Other <br /> R <br /> ck� State <br /> Lu d <br /> f- <br /> Z <br /> w EPA/Other <br /> V <br /> Lu <br /> N J. Additional Descriptions for.Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 0 iib/ , -da b. <br /> W <br /> Q 11d <br /> Z 15. Special Handling Instructions and Additional Information <br /> Q la_ 17 <br /> Z 24 IMP. h KM'F.N(,Y U N'IAJOT--PH��I�/L�IP' Al"IdLKE we i, Ill- r <br /> w (8W)321_.10-i0I Ie_ <br /> .HEAR TVX cr ;. . . z <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 /> If am a large quantity generator,I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N <br /> and the environment;OR,if I am o 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 /> ac available to me and that I can afford. <br /> OPrinted/TjypeoNome Signature ', - /�.._ \ Month Day/ Year <br /> w T 17. Transporter 'Acknowled emeni of Rjpceipt of Materials <br /> Rnth / ay i `(Rarer <br /> M Printed/Type f / Signet I•/ <br /> Lu <br /> LU S 9 [ <br /> P V, Y <br /> 0 18. Tra sorter 2 Acknowled em n of Recei t of Materials <br /> 0 NPrints /Typed Name Signature Month Day Year <br /> w E <br /> v) R <br /> U19. 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) �►r� /' �1 M Tj A 1� L! Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />