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For ..,r p:oveaOMB No.2050-0039(Expires 9-3 -99) - " See Instructions on back Of Page 6. Department of Toxic Substances Control
<br /> Pleose print or type. Form designed for use on elitj 112-pitch)typewriter. Sacramento,California
<br /> UNIFORM HAZARDOU 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> s not required b Federal law.
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<br /> WASTE MANIFEST of
<br /> 3. Generator's Na l and Mailing Addr ss ¢;t=;(,`,I. ", A. State Manifest Document Number ''``�� �,ppt� a.,Q,��;
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<br /> �, '•' a C: �-—+; r• B. State Generator's ID
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<br /> u7 A. Generator's Phone(r 0?) 47 1,—410,14 f l
<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.)
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<br /> D. Transporter's Phone { n
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<br /> r 7. Transporter 2 Company"Name - --- -- - 8.US EPA 1D Number E. State Transporter's ID[Reserved.]
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<br /> Q F. Transporter's Phone
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<br /> U 9. Designated Facility Name andSite Ad ress !S L +?t i. 10. US EPA ID Number G. State Facility's ID -
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<br /> 11. US DOT Description(includingPrope Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit
<br /> U P P PP g No. Type Quantity Wt/Vol 1. Waste Number
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<br /> = WA9TE L.(-11"I;OU, ` 'f BL.L L_IQUID fq, 0 `a. } i.
<br /> PFTR0i ;jM i�r`-+PH AAi NA1''9,3 1.PG1IEPA/Other
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<br /> R A£�:�iTk*;'.]i. Ek M 128 �NAPEi' />fi�.l r�.t 91.3 PG is IT � � 5 � � t r) i. EPA/Other
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<br /> h J. Additional Descri tions for Materials Lis ed Above K. Handling Codes For Wastes Listed Above
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<br /> Z 15 Special Hpndlmg Instructions and Add tional Information 'ir_'t•!-' L;.1`:.?:f�,.)'T.: .? l ,�r_:�✓ �t a(Cn iti l--9G:'-i.:�
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<br /> =+ 16. GENERATOR'S CERTIFICATION: I her 6y declare that the contents ofthisconsignment are fully and accurately described above by proper shipping name and are classified,packed,
<br /> Umarked,and labeled,and are in all r pects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> —J If 1 am a large quantity generator,I c 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 economically
<br /> o practicable and that I hove selected th practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
<br /> N and the environment;OR,if I am o s all quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is
<br /> Oavailable to me and that I can afford.
<br /> Printed/Typed Name , Signaturq // Montfs, .1 DayT ' jeer,
<br /> w 1 17. Trans otter 1 Acknowled ement of Re i t of Materials
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<br /> Lu Printed/T,y/y`ec!Name..z /r' Signature �/�• A � � „—. Month Day � Years
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<br /> ss_ 818. Transporter 2 Acknowledgement of Rec i t of Materials
<br /> 0 ed-Name _.._..._ -. _.... .Signature - .. - _. _._-_ ...__._... ..Month - - Day .Year
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<br /> (Qj 19. Discrepancy Indication Space
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<br /> 1 20.;Fceili Owner or Operator Certificatio of receipt of hazardous materials coveredb this manifest except as noted in Item 19.
<br /> Month Da Year
<br /> T Prlhted/Typed Name •'� - Signature �� '� � %
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<br /> DO NOT WRITE BELOW THIS LINE.
<br /> Yellow: TSDF SENDS THIS COPY TO GENEeTOR WITHIN 30 DAYS,
<br /> 0 2_`/ = v :J j }( } � (Generators who submit hazardous waste for transport out-of-state,
<br /> DTSC 8022A(1/99) produce completed copy of this copy and send to DTSC within 30 day.)
<br /> EPA 8700-22
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