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RECEIVED
<br /> mare or—urorma—cnnronmenrar rrorecnon regency •-- ��c-..(s'f 28 2Z
<br /> Form Approved OMB No.2050-0039(Expires 9-30- ) See Instructions on back of P, bs�OUi Department of Toxic Substances Control
<br /> Please print or type. Form designed for use on elite( 2-pitch)typewriter. OFF a'1'IV�V N 130UMy Sacramento,California
<br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. ag in the shaded areas
<br /> j is not re#red by Federal law.
<br /> WASTE MANIFEST of
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<br /> 3. Generator's Nam and Moiling Addres i-t!'�i w .L i_ - .5..!_. A. State Manifest Document Number i j
<br /> 21481849
<br /> O ,. 771,44<04 c:llFF s- '{•- - C s=' B. State Generator's ID
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<br /> 4. Generator's Phone( 2'0 rl 47-11-40 i.l' •;,,,•:`G 0= ,.f wi i::
<br /> (V 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.]
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<br /> 7 D. Transporter's Phone
<br /> 7..Transporter2Compony Name.._.. .. .__......... -..." ..8..US EPA ID-Number - E. State Transporter's ID[Reserved.]--- "" - - -
<br /> ri Q F. Transporter's Phone
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<br /> V 4. Designgted,Faci�ily�a�a 4nd Sif ¢dd ss. -' 10. US EPA ID Number G. State Facility's ID
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<br /> 12. Containers 13. . 't
<br /> ,•�•�V 11.US DOT Description(including Proper s ipping Name,Hazard Class,and ID Number) Total 14Uni i
<br /> No. Type Quantity Wt/Vol I. Waste Number i
<br /> Z a. Stale
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<br /> 3 G t2rr�i 29 ;ca. ?#Q2A _ (>OC)l r D0l9'4 0139 f'l040; � ;.. � EPA/other
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<br /> Z J. Additional DescriipLons.(or,A�"1 ials Lisle /above K. Handling Codes for Wastes listed Above s 7
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<br /> O 15. SQe cip arrl!dlin44 1pstruction�p]d Add ti nql Info n otion
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<br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and a e classified,packed,
<br /> U marked,and labeled,and ore in all res acts in proper condition for transport by highway according to applicable international and national government regilations.
<br /> i
<br /> --+ If I am a large quantity generator,I cart fy that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have deter fined to be economically
<br /> practicable and that I have selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and Tutu a threat to human health
<br /> N and the environment;OR,if I am a sma quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste m nogement method that is
<br /> Oavailable to me and that I can afford.
<br /> } Printed/Typad Name . r Signature y
<br /> 1 F M nth Year
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<br /> c, B 17. Trans ortei 1 Acknowledgement of Recei t of Materials
<br /> w p Printed/Typed Name Signature /1 nth Day Year
<br /> w 5 , , 4 r ,, ,'a,. .F.-.+ , f>,.^..!t•L-<�
<br /> 8 18. Trans orter 2 Acknowledgement of Recei t of Materials
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<br /> g_ Printed/Typed -- - Signature M nth Day Year
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<br /> V 19. Discrepancy Indication Space t
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<br /> 1 rPr,,n1?d/Type0d
<br /> 0. Facili wner or Operator Certification f receipt of hazardous materials cover' this manifest except as noted in Item 19.
<br /> T Name iYt ; Si afore r �s M nth Day Year I
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<br /> DO NOT WRITE BELOW THIS LINE.
<br /> Yellow: TS DF SENDS THIS COPY TO GENERATOR WITHIN'30 DAYS.
<br /> DTSC 8022A(1/99) !� ] -"i i -��: " .. , • J _ - -.V P (Generators who submit hazardous waste for transport out-of-state, i
<br /> EPA 8700-22 produce completed copy of this copy and send to pTSC within 30 day.
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