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State of California—Environmental Protection Agency �S Form Approved OMB No.2050-0039(Expires 9-30-P91 See Instructions on back of page 6. Department of Toxic Substances Control g Plecis e.�rint.o type. Form designed for use on elite 12-pikh)typewriter. Sacramento,Cali{ornia '! 1. Generator's US EPA ID No s,� in Manifest Document No. 2. Page I Information in the shaded areas UNIFORM HAZARDOUS If. i ;} /,1% i ,� is not required by Federal law. WASTE MANIFEST 1:4. G.;; r1I- of y r 3.'Generator's Name and Mailing Address A. State Manifest Document Number Int% I ';0— Pi -6 :s% A'r'`ycY S s {{ i C) -7�:!li:.til'.• r7Yg ic1$'�{i.3:?{L:a> u. .�t�:i�.J B. State Generator's ID. .skki C) F. A. Generator's Phone 520, Q ' N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Tronspprfoei ID(Reserved.] D Trgnsporter's Phone C) 9119 40 53M "T op 7. Transporter 2 Company Name 8. US EPA ID Number %E..State Transporter's ID Reserved.] `3 Q I F Transporter's Phone ., V 9. Designated Facility Nome and Site Add ss 10. US EPA ID Number G State FaciliVs ID - ]: H. Facility's Phone : V• J Q 12. Containers 13, Total 14Unit . Description(ncung Proper S iPPi g Name,HazarCass,anID Numer]V a No. Type Quantity Wt/Vol _ 1. Waste Number ' = ai'1a♦i S tote ;1!t 4 EPA/Other b. .. s-. Slate EART. O N cc cEr co R - EPA/Other v A -- o QUALIFIED Slate T FOR RECYCL NG/TREATMENT AT THE EPA/Other R beMENNO-/K RD LU d. CALIFORNIA.THIS FACILITY HAS THE NECESSARY State PERMITS TO RECEIVE YOUR WASTE STREAM AS II w EPA/011ier V LU Z 7 Addttioriol D,/yesgnpltor�far Mo�re7na s Lta b s ' NUMBER K Handling Codes for Wastes Listed Above � d. a 0 15. Special Handling Instructions and Adcliticiral information ' LitASYILTHE �:'xf>7 'rr•�t;at'WIEE 'y -ei>3;1?3 x'i# 1 4 ' _. �i .�iLi�` ........:'.�' �TE,7••f.:.i�tisS? �a.:r Zl4 �i eL7., i'�iv�t'i.v�31 �s �:�— f'�':7 / 1 ,..{� vfc'3+R"- y1+�t? �'/•: t ' "p1?If.v` C ;AVS: CLOTHING 1349-699-370f; t 2 4-hL+urs. r s " � "i z> ,'7 11 16. GENERATOR'S CERTIFICATION: I hereb declare that the contents of this consignment are fully and accurately described above by propershipping name and are classified,packed, Umarked,and labeled,and are In all respects in proper condition for transport by highway according to applicable international and national government regulations. % —J If I am a large quantity generator,I cer i�y that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically n practicable and that I have selected the pFadica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health to and the environment;OR,if I am a small)gvontity generator,I have mode a good faith effort to mininiizc my waste generation and select the best waste management method that is available to me and that I can afford. O } Printed/Typed Name Signature Month Day Year it „l Z I,.Y71':C"}{ L1:1sk�.yt�3X"�: AYi�.'.ri� 1. 'i 'It'-S'..�f.'�}0,"rys?S a�.�7.i:•, .4 t��" i•.•,. r. .. j -�+ �� i'� I J J w T 17. Transporter 1 Acknowledgement of Recei oj Materials 7 r R ` nature sv.-�» - .... y LU A Printed/moped Name i g - , Month Do yy Year Si wS `+'•., ti• `rr.. }...,._ s° _ is 1 rt l u- P g 18. Transporter 2 Acknowledgement of Recei of Materials t R Month Da Year ] � T Printed/Typed Name i Signature - Y w E N R .t U19. Discrepancy Indication Space j z A C I r L 20- Facility Owner or O erator Certification of,receipt of hazardous materials covered by this manifest exce t,o;noted in It 19. : T , Signature ,Printed/Typed Name ��y'r Month Da Year yy �r�! y 7! Y k DO NOT WRITE1BELOW11-k�- 1 FAC# j 1�5Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. $: DT OYYh•ff fs] _ (Generators who submit hazardous waste for transport out-of-state, 4 EPA 8700-22 produce completed copy of 'his copy and send to DTSC within 30 days.] .;