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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 e 6. f
<br /> Please print or type. form designed for use.on elite(12-pitch)„ Department oToxic Substances Contra
<br /> -iter. Sacramento,fToxic California
<br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> is not required by Federal law.
<br /> WASTE MANIFEST 1 1 of I
<br /> 3. Generator's Name and Mailing Address } A State Manifest Document Number
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<br /> Ld?vLLACE LAC7L1FT1.17= "ase S+1TP�'•f6 I .e .l�fvil $ '223901165,
<br /> 23213 ?,t3'E1�£r24C'L" P10" C I,. CA
<br /> O B StateGenerator's!D
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<br /> A. Generator's Pone
<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's lD{Reserved.] - -
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<br /> Osz. /1• Ips Ir! �Ir D Transporter's Phone
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<br /> �■/�Y) r, 7- Transporter 2 Company Name 8. US EPA ID Number E. State Ttnnsporfer's�fD[Reserved]
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<br /> F. TranspoFter's Phone
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<br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G State Facility's ID
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<br /> Z 2� H Facility's Phone
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<br /> 12. Containers
<br /> MV 13 Total 14 Unit
<br /> 1 L US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type_ Quantity Wt/vol I Waste Number
<br /> Z a. L'L�L�PL T,IJiS. ta.O.E. . 3, TffiI.933. PtE IT State
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<br /> 'EPA/Other.-.23.
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<br /> '�1 o , EPA/Oilier
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<br /> J.',�aJdi�i nal Dcr` ty�o;s.f�o£ s;e ials 1�i fw�dd Above ` K. Handling Codes for Wastes Listed Above
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<br /> Q - 15. Special Handling Instructions and Additional Information
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<br /> Q !sx7].119i]±i, erase; u:x sakm3 s�,�or r,:� ca 49 1^E: 17l,12t- Jam$ 14,83-06364
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<br /> _ p 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 /> Q marked,and labeled,and are in all respects in proper condition for Transport by highway according to applicable international and national government regulations
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<br /> � 6
<br /> -_ If I am a large quantitYy 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 /> 2 practicable and that I have selected the practicable method of treatment,storage,ortdisposal currently available to me which minimizes the present and future threat to human health
<br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to mini l e my waste generation and select the best waste manasement method that is,
<br /> Oavailable to me and that I can afford. ' ' i /�.
<br /> } Printed/Typed Name ��:;�t�.A C z��' Sonatu v/� ,/ Month Day Year
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<br /> 17. Transporter I Acknowledgement of Receipt t of Materials
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<br /> LU A Printed/Typed No - Signa�� !t/ f j Month Days- Year
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<br /> aU- a 18..Transporter 2 Acknowledgement of Receipt of Materials
<br /> T Panted/Typed Name : Signature Month Day Year-
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<br /> V 19. Discrepancy Indication Space - - -
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<br /> 1 20. Facility Owner or C) erator Certificatiop of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name `?`-it, s ', + - Signature Month Day Year
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<br /> N5` DO NOT WRITE BELOW THIS LINE.; $
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<br /> p DTSC,8022A(1/99)
<br /> Ya1�aC� GENERATOR RETAINS
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