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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-70-94)I See Instructions an back of F 6. Deportment of Toxic Substances Control <br /> Please pent or type. Form designed for use on elite(T pitch)typewriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. G'enerator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST <br /> is not required by Federal law. <br /> I 2 I I I / of <br /> 3. Generator's Name and MailinSLAddre <br /> CN _ r <br /> 4. Generator's Phone ( ) TGA <br /> co <br /> O 5. Transporter 1 Company Name / 6. US EPA ID Number <br /> IC�fy�cal J,%�aT/f''i�.✓J!rte <br /> 7. Transporter 2 Company Name 8. US EPA ID Number 5101sT„ Jp <br /> NV�} h -_ <br /> �1 1i' <br /> C 9. Designated Facility Name and Site Addless 10. US EPA ID Number G.5tnW w <br /> CCS GyF.Hi�91 k�AfjF�'�.r �iy //f-G Rob01 , �t. <br /> OA� RD I <br /> ^te^ a' ' A D V11, 0-M..' ' <br /> W 12. Containers 13. Total 14, nit <br /> 11. US DOT Description(including Proper Sipping Name,Hazard Class,and ID Number) <br /> No. Type Quantity Wt/Volk3: <br /> 3 G <br /> t'oa�N I�E :,.3 x <br /> CIO N b. <br /> E <br /> CN R <br /> � A <br /> 0 <br /> o T C. <br /> 00 <br /> w R <br /> Y. <br /> ~ d. <br /> U <br /> LL) <br /> � Y�;, E�eArgstions.io� a(sE.. t<'iow�i��CodeRforziMastas,Fiseed - <br /> CL <br /> V) <br /> Q15. Special Handling Instructions and Additional Information 1 <br /> f- <br /> a <br /> Z <br /> UJ <br /> � 16. GENERATOR'S CERTIFICATION: I her <br /> declare that the contemn of the consignment aro fully and accurately described above by proper shipping name and are classified, <br /> J <br /> packed,marked,and labeled,and are i all res in proper condition for transport b highway according to applicable federal,state and international laws. <br /> Q P P� P P� � Y 9 aY n9 PP <br /> U <br /> If I am a large quantity generator, I ca rtify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be c <br /> economically practicable and that I h selected the practicable method of treatment,storage,or dispos&Cutremfy available to me which minimizes the present and future <br /> CL threat to human health and the enviro ent; OR, if I am a small quantify gener ,r, I have made a good fcith effort to minimize my waste generation and select the best <br /> to <br /> waste mono ement method tR t is Quail le to me and that I can afford. <br /> � a1i Signature � Month Day <br /> Year Printed/ -I - <br /> U <br /> Z T 17. Transporter 1 Acknowledgement of Rece t of Materials <br /> R <br /> NPrinted/Ty a e.. Sign re Month Day Year it <br /> P <br /> LU <br /> 0 18. Transporter 2 Acknowled ement of Recei t o Materials <br /> W T Printed/Typed Nome Signature Month Day Year <br /> LL E <br /> p R <br /> W 19. Discrepancy Indication Space <br /> V <br /> Q F <br /> V A <br /> Z I C �. <br /> _ <br /> L <br /> 20. Facility Owner or Operator Certification ilif receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> I , 1 7 1 1 <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A (7/92) <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br /> EPA 8700-22 <br />