Laserfiche WebLink
State of California—Environmental Protection Agency — l:'_i- ` <br /> Form Approved OMB No.2050-0039(Expires 9.30- 9) See Instructions on back of r--e 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 12-pitch)t ler. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Addres :?t_.`...... A. State Manifest Document Number <br /> O -;t,: ".-:!"'{{.]i',) (!<^sr a^s rkr•'f:�."f.-.A}C:19!5 B. State Generator's ID <br /> .., .. .. ` <br /> N A. Generator's Phone( t`') I <br /> & 5. Transporter 1 Company Name 6. US EPA ID_Number C. State Transporter's ID[Reserved.] <br /> LO <br /> _ D. Transporter',Phone / Cy <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> J - <br /> J F. Transporter's Phone <br /> Q <br /> V 9. Designated Faahty.Name and$rte Addr ss 10. US EPA ID Number G. State Facility's ID <br /> Q } r'1''dCk <br /> H. Facility's Phone <br /> OU_ <br /> L .. - .. <br /> Q 12. Containers 13. Total 14. Unit <br /> 11.. US DOT Description(including Proper S ipping Name,Hazard Class,and ID Number) <br /> No. Type Quantity Wt/vol I. Waste Number <br /> = a :.L.. <i\lis State <br /> i t U , Q-UT t']_ C }F t r <br /> rr.. yi 77. .).. .: ,. - .; ,� ..� EPA/Other <br /> G �i�'�...;_.t ftl 1 E`1 E'r3'ri i:l I'tif Y...it• 1. '. - t {- 4i � C.. <br /> O N b. State <br /> co <br /> coo E r <br /> a R EPA/Other <br /> CN A <br /> O TC. <br /> State <br /> a0o O <br /> R EPA/Other <br /> CL, d. State <br /> H <br /> Z <br /> w EPA/Other <br /> V - <br /> w <br /> N J. Additional Descriptions For Materials Listed Bove K. Handling Codes for Wastes Listed Above <br /> Z <br /> O b. <br /> CL <br /> V) <br /> LU <br /> C. d. <br /> J <br /> L5. Special Handling Instructions and Additiot al Information <br /> Q <br /> Z <br /> LLJ <br /> 16. GENERATOR'S CERTIFICATION: I hereby eclare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Umarked,and labeled,and are in all respe is in proper condition for transport by highway according to applicable international and national government regulations. <br /> J <br /> J If I am a large quantiy generator,I cern 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 /> a practicable and that I have selected the p cticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small uantity generator,I have•mde mood faith effort to minimize my�+aste generation and select the best waste management method that is <br /> Oavailable to me and that I can afford. t / <br /> VPrinted/Typed Name Signature Month Day Year <br /> TR 17. Transporter 1 Acknowledgement of Recei t of Materials <br /> ua p Printecj/-Typed Name Signature Month Day Year <br /> N <br /> S 31 <br /> ul0 18' Trans orter 2 Acknowledgement of Receipt f Materials <br /> 0 T Printed/Typed Name Sigrsature'' Month Day Year <br /> LU E <br /> L0 R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Foci ity Owner or Operator Certification a jeceipt of hazardous materials cover by this manifest except as noted in Item 19. <br /> T Mi ted;Typed Name'1 tu �� ,+' Month Day Ye <br /> Signoarn <br /> A )" N%14 <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (1/99J (Generators who submit hazardous waste for transport out-of-state, <br /> produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />