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State of Califunim Envirunmental Piofuchun Agency <br /> Fm'm Approved OMB No,2050--0039 1Expims 9 30 99) i S@@ IIISfrUC{'tOT15 on bOCI( OF@ 6. <br /> Please print or type. Form designed for use on elite(I2-pitch) iter. a Department of Toxic Substances Control' <br /> Sacramento,California <br /> UNIFORM HAZARDOUS venerator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST s, C ) Zt C, (')({ , 1 ( . �(� A. State Manifest Document Number�A of f is not required by Federal law. <br /> Cy <br /> 3. Generator's Name and Mailing Address 1 YJ <br /> � � � �� ► r-.ac ����r 21806468 <br /> O S. State Generator's ID <br /> LO <br /> 4. Generator's Phone C <br /> s(V 5, Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> ao <br /> 6Aflf 0-`fls,AN VALIl..tA WA'--t Iii:, OR � A i- it (,t (1 ,9 �f � j �j D. Transporter's Phone 8k0-732-W45 <br /> ao 7. an Trans orter 2 Com N <br /> /6�j/��/ P P Yame 8. US EPA ID Number E. Stats Transporter'.ID[Reserved.] <br /> 'q J <br /> W Q I I I I I I I I 1 F. Transporter'.Phone <br /> q4T tJ t9lt4je�ig Ijrfp$jktty Te 9rfkTiTH� sf 10. US EPA ID Number G. Stu aAytIDO 0 1 9 0 8 'tl e;; <br /> Z )JW) ( l AI-1ti N A1.) <br /> 0 fm 0f�IIVf_.uil:[11NK 6-A W636 >'l L. 1) 0 U 1 f,l u "I ki H. Facih 's Phone <br /> J <br /> Q <br /> V 1 l. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. UnitNo. Type Quantity Wt/Vol I. Waste Number <br /> o. S'J+)FI 1(!",I A I I,A!Ai0)(JON WAS1 t: I If,;II,➢I0 State <br /> i 1lt i 'u1ifal .(� ) t, <br /> � 1, a i 1 ,, a `% EPA/Other <br /> 3 <br /> a N b. <br /> State <br /> co E <br /> R EPA/Other <br /> v A <br /> o T C. <br /> State <br /> 00 O <br /> R EPA/Other <br /> aUj< State <br /> d. <br /> Z <br /> V EPA/Other <br /> LU <br /> ZJ. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O 0II..Y WAIEH a' 1i1 b <br /> CLV) <br /> LU <br /> C. d. <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> H <br /> Z <br /> r,, f P/1F IIIA-1111 1' f l it IP!! '!O!D Yil:i'f ow."." <br /> x <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consi nment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and nationol government regulations. <br /> J <br /> —r 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 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 and the environment;OR, if I am 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 /> ck� available to me and that I can afford. / <br /> 0 <br /> >- Printed y d Name �•'t -�•- - ,) j Signatyw , nth Do Year <br /> _ , c..- <br /> N A— <br /> ]if. Transporter Acknowledgement of Receipt of Materials •'�— <br /> 7-1 <br /> W RA PrinOa/Typ Narge 4':'" Signgtor s , Doth Day Year <br /> y <br /> W0 s18. Trans orter 2 Acknowledgement OfTfecei t of Oaterials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> w E <br /> R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> I 20,Facility Ownor or Operator Cedification of rucuipt 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 /> DISC 0 (1/99) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br />