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State of California—Environmental Protection Agen -?—• Form Approved OMB No.2050-0039(Expires 9.30. 9) See Instructions on back of page 6. Department of Toxic Substances Control Please print or type. Form designed for use on elite 12•pikh!typewriter. Sacramento,California UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. T. Page 1 Information in the shaded areas WASTE MANIFEST =t c'O ``'' `' r; °1' 7 is not required by Federal low. of 3. Generator's Name and Mailing s Adde�lre s .`r�+�.• - _.. A. Slate Manifest Document Number 24436455 �._t,,._it:,:� B. State Generator's ID � - I I LO A. Generator's Phone(23"?) .4��.'' -_1 t�i t :.j li r/ a Y__l1_ cV S. Transporter 1 Company Name 6. US EPA 10 Number C. Slob Trarsporter's ID(Reserved.] In D. Tronsporter's Phone O� o 800 669-5740 c? 7. Transporter 2 Company NamNumber E. Slate Tran Name B. US EPA ID Nb ' J Wor1Ns ID IR� ] LO 494,Q F. Tran,p..I,Phone ,pps�p�sp�Qd FaF' yo n to A 10. US EPA ID Number G. State fpSjfips'},I 4 3 fJ CC sF1r � 1 t' r��'1dt:-P+� �4 ; t'ii ?int: pi(Cl .I;rz SAL.I f.,A H. Facility's Phone 209 545-1011 NQ tJ 11. US DOT Description(including Proper ipping Name.Hazard Class.and ID Number] 12. Containers 13 Total le. Unit No. type lJuannry wt/Vol I. Waste Number Z a. 's r,.. ' l ?►.1 State _ ti_ F F~(T:lsx ;,Lt �iVB..�, I'•.. f� i. U T'i. DIM !; 134 F— IS3ti t} (Nt] CiSr1 :. OR t_!-L_PA 3 G r':r1Vf:f_:1(.�!.i ��f`.T[i H{Ei�k-{t�'i `=,�]I..l.}F ILIP,I iii '3gr(:�il C! EPA/Other E o N b. state co E 4 R EPA/Other v A �- o T State w O R EPA/Other ac r d. State Z w V EPA/Other w ZJ. Additional Descriptions for Materials List.0 Above ic tlanrRl..a roil«f—Wass..Listed A6— O a. 14 b. n. w Cc c. d. s Q O ._. 4.. �'t C.F" C..].Y "t t.`r t" '7F'-1. .-y '•—. •r_r.. .==Fit.t.' Q Z :a? Tf +•'a:t� ? 3 hi..�� tri; :TI rte J( hf 4 16. GENERATOR'S CERTIFICATION: herab declare that the contents of this consign are full and accurate] described above b proper shi in name and are classified, Q g Y y y P P Pp g pocked, V marked,and labeled,and are in all res ects in proper condition for transport by highway according to applicable international and national government regulations. IF I am a large quantity generator,I car.Fy that have a proram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically Npracticable and that I have selected the rocticable method of treatment,storage,or disposal curvejS'tly available to which minimizes the present and Future three]to human health and the environment;OR,if I am a sma�quantity generator,I have made a good faith effort to r,Ttnimize my waste eneretion and select the best waste management method that is O available to me and that I can afford. /I } Printed/Typed Noms ` Srgnalure I / Month Day Year w V' T 17. Transporter 1 Acknowledgement of Recei t of Materials R w X Printed Name t Signature A-11, n,.,y Y— w S � A'�1 mq At/ 1'3 ice/ P ss_ 0 18. Transporter 2 Acknowledgement of Recei t of Materials O R Printed/Typed Name wure Month Day Year N F Q R V 19. Discrepancy Indicotion Space Z F A C L I 20,,rkility Owner or Operator Certification of receipt of hazardous materials ver this manifest exce t as oted in Item A 9[% T Pr ted No Si not e Y /7 smonthDaar l//A1 I� t— D NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPYTO GE RATOR WITHIN 30 DAYS, DTSC 8022A(1/p9;)lj-]+= „}^1,1�;� _ IGeim�utors who submit hczar ous waste for transport out-of-stets, EPA 8700-22 ' '` r H f -1 G:�4':_'t('I proauce completed copy of this copy and send to DTSC within 30 days) 1._