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State of California—Environmental Protection Agen y ' <br /> Form Appr ved OMB No.2050-0039(Expires 9-3 -99) See Instructions on back of Page b. Department of Toxic Substances Control <br /> Pie int or type. Form designed for use on elit (12-pitch)typewriter. Sacramento,California , <br /> UNIFORM HAZARDOU71 <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Pa�InFormation the shaded areas <br /> by Federal law. <br /> WASTE MANIFEST o <br /> 3. Generator's Name and Mailing Add ss f"AU;t.I• .i,-L ?,:L1_,j,.. A. State Manifest Document Number 5 <br /> 509'-" 3FECKDON <br /> 6121 <br /> O "i'•� I.Y , Gi. is -,.. <br /> ir1 f Cl*�hi I!' _,-.]':�.�:-' s.! B. State Generator's ID <br /> LO A. Generator's Phone( ._i(.�''?'[ •'•1.. w•"^ 0.j.4 <br /> ie n <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID.Reserved. <br /> LOop <br /> P [ 1 <br /> D. Transporter's Phone <br /> o I <br /> 7.Transporter 2 Company Nome, .. . . .8.,.115..EPA ID Number E. State Transporter's ID[Reserved.] <br /> J <br /> QF. Transporter's Phone <br /> U 9.fpesipngigd Fa�rl'tpar pndr�ikq A rasa y + 10. US EPA ID Number G. State Fac:Mxs ID � <br /> Q ,,;i E TY par <br /> f; f'1 'f •''i'.".ti <br /> ' ce A w...i Tlv+ I .int !..A e +( (.�6 j 3t?6e H. Facility's Phone <br /> T—i Q12. Containers 13. Total 14. Unit <br /> U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> = a If•� 4 G n!v)�.f�.> �.., f..rS F T- i_. State <br /> '' Id'9�Lt 11�! f}w"yF'Fi �F11 f Iz f��'•!;_3 <br /> P , <br /> 3 G Y':i"y:4.7.22l) 6, . LM f!•ttl_ S 1)f.?.-'`.s'°j ' EPA/Other <br /> p N 6 State <br /> co E <br /> -t R EPA/Other <br /> v A <br /> o T c <br /> State <br /> C'6 O <br /> R EPA/Other <br /> Cie <br /> LU d <br /> F- <br /> . State <br /> Z <br /> w <br /> U EPA/Other - <br /> 6 <br /> LU <br /> ZJ. Additional Descriptions for Materials List Above K. Handling Codes for Wastes Listed Above <br /> O a. 6. <br /> W <br /> C. d. <br /> Q <br /> QIS Srcia�Handl!n Instructions and Add_i onal information �: a t I!: <br /> � f..:f;'t..•*i«.I wl i;� ��:.::�}' si' a{,1" �:�', 7 - r::.xf"{fi <br /> Q <br /> Z <br /> w <br /> 2 71.'f Ij i <br /> � .:j;. - el= i�. t•]�'[ i��i., c�.T.t.<t t.,ty�..Li1`. .. <br /> 16. GENERATOR'S CERTIFICATION: I here y declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all re acts in proper condition for transport by highway according to applicable international and national government regulations. <br /> I <br /> If I am a large quantiy generator,I ce tify 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 j <br /> n" practicable and that I have selected the 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 1 am a sm II 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 /> } PrintRd/TypedlN� e f 0 Sig afu y ✓':' _ i Month Day Year <br /> !;{,Ir r,t_t/`f ;+f '-�1_ �1`�1/ ���,�s",I y✓t �'..,�:.� -,! ;�',: ��1 `•,` ::,•� '�'"f� :� <br /> Z F' i <br /> w T 17. Trans orter 1 Acknowledgement of Rec Fit of Materials - I <br /> w p Prilnted/Typed Nae r 1 Signature �� A. �� ., Month Day Year} <br /> LU <br /> S `t �7' �,t��7'i y� •✓'�s• / r �'�•r' moi" '1 ,• .. !'. !i' <br /> u_ 0 18. Transporter 2 Acknowledgement of Rece pt of Materials ' ' <br /> T —[--M <br /> Printed/Typed Name Signature onth Day Year <br /> w E <br /> Q R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 I <br /> 20. Fq li Owner or Operator Certification f receipt of hazardous materials covered-6y this manifest except as noted in Item 19. ) <br /> T Printed/Typ d Namef.�+ ..J !'•�^1 Signature :/ d� Month Da Year ' <br /> J >. i <br /> —.}DO NOT WRITE BELOW THIS LIME. i <br /> Yellow: TSDF SENDS THIS COPY TO NERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 04 <br /> —29—OZP01 :�'-f R C V D produce.completed copy of this copy and send to DTSC within 30 ) l <br />