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State of Californio—Environmental Protection Agency / ) r/L"�b <br /> Form Approved OMB No.2050-0039(Expires 9.30-94 See Instructions on back of pr- - 6. / /' Department of Toxic Substances Control <br /> Pleas!!i - r'Yjp Form designed for use on elite(1 itch)yF .,d Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS snot required by Federal law. <br /> WASTE MANIFEST Q 2 j of <br /> 3. Generator's Name qad Mail' ddress A. State ManifestDocumentNumber aTri <br /> LO <br /> so �+� , ►r�G w� 9244824 ;:; <br /> 6� S. E oltAlX� B. State'Gorwatorit tlD <br /> J <br /> � 4. Generator's Phone ( ) -/vcxl�y /210,9/1 <br /> ap G/'c l <br /> O 5. Transporter 1 Company Name 6. US EPA ID Number a Stab Transporterts,ID 3)1Y 3 y�-"F <br /> C/t1G41laTE.�y'/,�lE/1E✓%/rc �+ /,ffl -j $/�sJ <br /> J <br /> O 7 �I D.Tran sparft's Phone <br /> J 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID _ <br /> F. Troruporter's Ph. <br /> CCZ`C= 9. Designated Facili N me and Site Address 10. US EPA ID Number G. Stade Facil' 's <br /> H. Facil Photo <br /> �T11�-�- v GTT G�1 G 7-1001 o vl <br /> 12. Containers I 13. Total 14. nit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and <br /> ID Number) No. Type Quantity (}Wtt//Vol I- Was,.Number - <br /> f �� a. Hf�3�n/Jr��/'rJ ��j(/ s�.'��-j� O i� �� 77+� State Q .f <br /> 3 G /Y/9 d�0/ / G .ZZZ: / j EPA/Other�.(Jj�f! <br /> 04 E <br /> 00N b. State <br /> i 00 E <br />} <br /> NEPA <br /> SR A� � /� <br /> O <br />' p T C. State <br /> EPA/Other; <br /> I � R :. <br /> LU <br /> Z d. State <br /> Z w., <br /> U EPA/Other, <br /> w <br /> Z l Ad&ti ..I Degcriptions for MateridsAbore K. Handling Godes for Wastes Listed Above <br /> 0 0i b. <br /> LU <br /> ` <br /> d. <br /> Z - M Kr . <br /> O 15. Special Handling Instructions and Additional Information <br /> F-- <br /> LLJ <br /> i�G Oo z` <br /> .� 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> J <br /> packed,marked,and labeled,and are in all respects in proper condition for transport b highway according to applicable federal,state and international laws. <br /> Q P Pe P P P Y 9 aY 9 PP <br /> V <br /> If I am a large quantity generator, I ceetify that I have a program in place to reduce the volume and toxi ity of waste generated to the degree I have determined to be <br /> J economically practicable and that I have selected the practicable method of treat ent, storage,or disposd cu rently available to me which minimizes the present and future <br /> CL threat to human health ane environ t; OR, if I am a small quantity generat r, I have made a good f th effort tr minimize my waste generation and select the best <br /> v7 <br /> waste management <br /> method that is av ila le to me and that I can afford. <br /> Q Printed/ yp Nam Signature \ r s Mont Day ar <br /> 71 <br /> v \ �, <br /> Z T 17. Transporter 1 cknowled ement of Recei t of Materials <br /> R /LU n Printed/Ty a Sig re Month Day ear <br /> W 5 G9ij <br /> 0 18. Transporter 2 Acknowledge of Recei t of Materials <br /> LJ R Printed/Typed Name Signature Month Day Year <br /> LL. <br /> 0 R <br /> LU 19. Discrepancy Indication Space <br /> V) <br /> Q F <br /> V A <br /> Z C <br /> — 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification 4 receiprof hazardous materials covered by this manifest except as noted in Item 19. <br /> Y Printed Typed Name• Signature - Month Day <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />