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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99)a See Instructions On back O e 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch*liter. Sacramento,California <br /> y ,. 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS +y required by Federal law. <br /> ' is not re' " BC ,£ y A^.'°_,0` <br /> WASTE MANIFEST I <br /> 3. Generator's Name and Mailing Address <br /> 0I <br /> SAMAROM MW <br /> LWI <br /> u9� 4. Generator's Phone ( "' Ct�. e1rx: �t� `.a ,: ,>i,. �`''" '" <br /> y <br /> r d s g i.ta <br /> N 5. Transporter 1 Company Name d 6. US EPA ID Number �5s`• <br /> 6 RMIC &dti VIfi4dc4��iiAEAL TM 'B S L 1 t —I <br /> O <br /> O <br /> 7. Transporter 2 Company Name 8. US EPA ID Number <br /> Q <br /> V 9 YC's ��. Cj};5917,�s" "k� Z <br /> Z 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> f•'.' 1 �r�.6$'lfuX;S„Jt7 a {.. C L,G}I r - r ^w <br /> i Ct e, tP � ��U w i <br /> �_ Yet TD, a A 94'303Vis„ <br /> mm� J <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 1 3 Total 14 Unit <br /> P ( 9 P PP 9 No. Type Quantity Wt/Vol r.-., . <br /> H <br /> E <br /> o N b - <br /> °D <br /> co E <br /> R M1# E 328%7 ERR 127 '#, Z- t°-P <br /> C14 A <br /> 0 ¢� RESIDUE, LIM XAI t�1 �) <br /> s. <br /> � d. <br /> V <br /> u= A�`�' n,.a A;m � s fi�3-"� ;:^aj� x�,z� A .:.na.�''��.'a� .'�?artlft" .�SdeS�tst' tts�tes CrsteC��t•'baYR ��sw;�,�.,, �°-... �....,; <br /> to � ” <br /> LU � �a <br /> Q n, <br /> 0 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> LU <br /> S <br /> H <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 /> Vmarked,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 /> J If l 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 /> CL practicable and that I have selected the practicable method of treatment,storage,or\lisposal 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 fa}th effort to minimize my waste generation and select the best waste management method that is <br /> tY available to me and that I can afford. .- <br /> O Pr: yped Name •'~ fSignature , Month ^g <br /> Day Year <br /> Z _ <br /> 6, c, <br /> ZD' T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU R 'Pr a ped Nome Sig Lure Month Day Year <br /> rr'"''9t!'"' t� y �•-• <br /> U- 8 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 RPrinted/Typed Name Signature Month Day Year <br /> T <br /> w E <br /> < R <br /> Q <br /> 19. Discrepancy Indication Space <br /> Z IF <br /> A <br /> C <br /> L <br /> 20. Facilitv Owner or O erator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> Rfaee '" DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />