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rnia—Environmental Protection Agency
<br /> ved OMB No.2050-0039(Expires 9-30-99) ! S@@ Instructions on back Of F1 j
<br /> s nt or type: Form designed for use on elite(12-pitch)type�r• 6• Department of Toxic Substances Control
<br /> Sacrdrnento;.ColiFornio
<br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> WASTE MANIFEST fir., -A I In I n I T 1 t '-7 j of 3 is not required by Federal law. j
<br /> 3. Generator's Name and Mailing Address C� ?
<br /> RTERLAKE _ f ERJAL HANDLING INC A. State Manifest Document Number
<br /> `1. S. Sed NTC}+SJ t►i T t ' era r : + i. 'LO Uzi P114
<br /> I_OIICA Generator s ID.
<br /> to A. Generator's Phone( 1
<br /> C', 5. Transporter t Company Name
<br /> 6. US EPA ID Number C, State T1.64pnrtar's ID[ eserved.]
<br /> 941ROIt M NTAL RECOVERY WRV00
<br /> D. 'a#ssparterrs Pharce r'; f
<br /> 7. Transporter 2 Company Name 8. US EPA ID Number I
<br /> J E. State TFcm orter's tD Reserved.j
<br /> j
<br /> Q F. Transporter's Phone
<br /> V 9. Designated Facility Name and Site Address
<br /> Q10. US EPA ID Number
<br /> s -C J Ir ,,,Y G. State Facility's ID
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<br /> ad
<br /> phFl 4.�`t't
<br /> H. Facility's Phone
<br /> J u�:.f `° �.�C�, �T ," •'tE :i :i ; �. '.i d�t s !,i Pr7 .�
<br /> J1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers
<br /> 13. Total 14. Unit
<br /> No. Type Quantity Wt/Vol I. Waste Number
<br /> E tk*4 KRA WORDOjis WASTE,SOLID tpAW,WWS)
<br /> GP
<br /> E }
<br /> fi Z �W> EPA/Other
<br /> b �,
<br /> o E NON F?4» I ` DAUS WASTE,:SOLV) D -,State
<br /> R
<br /> 7 A d/C p r! EPA/Other
<br /> T �.
<br /> i O
<br /> NON RCRA;RkZARDOUS'WAST ., SOLID state
<br /> R d. }� f Lw E�Other d
<br /> State
<br /> t )
<br /> t EPA/Other
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<br /> A a R2_WHandling Codes for Wastes Listed Above ocke
<br /> d con
<br /> um
<br /> 15. Special Handling Instructions and Additional Information eth
<br /> EMERGENCY CALL ENWRO-SERV 1-,5V_4Zj,,_,727
<br /> Day
<br /> &31Lt. TO BWONPAENTAL I I t 4'I "k` CESUSEPROPERWETY EQUIPMENT
<br /> I .
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<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 /> marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> 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 /> 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 /> and the environment;OR,if I am a small quantity generator,I have made d good faith effort to minimize my waste generation and select the best waste management method that is
<br /> available to me and that I can afford.
<br /> Pr /Typed Name %
<br /> Signature
<br /> MonthDay Year
<br /> R 17. Trans orter 1 Acknowled ement of Recei t of Materials
<br /> A nted/Typed Name
<br /> N $_J ' t �r Signature
<br /> Pt'`` a�+G- f�, C...r,,"wt ja'.A {yT Via) �-• 7 •,..., ...,.s+..,.,,, tl`""`'^...... 4.,,,,,, Month Day Year th
<br /> ` - ' l A C� 4s
<br /> 0 18. Trans orter 2 Acknowledgement of Receipt of Materials
<br /> T Printed/Typed Name
<br /> E Signature Month Day Year
<br /> R
<br /> 19. Discrepancy Indication Space
<br /> F •N 30
<br /> A
<br /> C nsport
<br /> l to D7.
<br /> L -
<br /> f20. Focili Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19:
<br /> YT i /Typed Name Signature
<br /> Month Day` Year
<br /> DO NOT WRITE BELOW THIS LINE.
<br /> 8022A(1/99)
<br /> 8700-22
<br /> Yellow: GENERATOR RETAINS
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