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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-3099) See Instructions on back of nage 6. Department of Toxic Substances Control <br /> Please print or type. Farm designed for use on elite(17-pitch) niter. Sacramento,California <br /> UNIFORM HAZARDOUS t' inerator's US EPA ID No. Manifest Document Nu. 2. Page 1 Information in the shaded areas <br /> no <br /> required by Federal law. <br /> WASTE MANIFEST °f; t;} 10121E i) 1 c,; ;� �.� ' -) /� 01 <br /> 3. Generator's Name and Mailing Address <br /> f, <br /> (4°%'a s1 Et (f ' A. State Manifest Document Number 21806574 18h6V74 <br /> C vi ^ B. State Generator's ID <br /> in <br /> 4. Generator's Phone ( , <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> to <br /> cp { <br /> D. Transporter's Phone -}..( L•'' ,k� ;} <br /> O <br /> ap 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> �-J <br /> F. Transporter's Phone <br /> ♦� 9,1Q0iIgPP{0F9Qiji#y N9me gn0i.4l(q#d reiti t i 10. US EPA ID Number G. Slot(facky'LIDt) t7 •I �! t3 "2 to <br /> C)oc I H. Facility's Pho e, <br /> 114 11 b I <br /> J <br />� <br /> yV 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> 4 V No. Type Quantity Wt/Vol I. Waste Number <br /> Z a. p2:::>f1 (}. :l ., ii:4: ?. +'';14 )p ;r4ifr, 1-10tlllb State nos ] <br /> 3 Gti EPA/Other <br /> o E N 6. <br /> State <br /> coCE <br /> R EPA/Other <br /> C14 A <br /> o T c <br /> State <br /> aoo O <br /> R EPA/Other <br /> rid <br /> F d. State <br /> Z <br /> w <br /> U EPA/Other <br /> w <br /> ZJ. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 0 011.. INA V,i a. f+'d b. <br /> a- <br /> 4`0 <br /> Lu <br /> c. d. <br /> J <br /> Q <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> ( �J91._it_,[ #lr��•ti' I"III.i�3l 'W'80'•t {3ttl 23r+': <br /> i <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 /> (a1 marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J <br /> If 1 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 /> d practicable and that I have selected the practica6le method of treatment,storage,or disposal 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 minimize my waste generation and select the best waste management method that is <br /> Oavailable to me and tat i c4 ]ford <br /> VPflnt y,q!T{Y ed Na .kms+Y Signature , I !+ Month Day / Y3ar .., <br /> N17. Transporter 1 Acknowled ement of Recei t of Materials r , <br /> Lu p Printed/Typed Name Signature Month Day Year <br /> P r <br /> 1i0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R <br /> Printed/Typed Name Signature Month Day Year <br /> Lu E <br /> to R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <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 hintud/Typud Nor— Signulure ----- Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 0 (1/99) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br />