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✓+ State of California—Environmental Protection Agen y
<br /> Form Agpioved OMB No.2050-0039(Expires 9-3 -99) See Instructions on back of Page b. Department of Toxic Substances Control
<br /> rfl #""'-rFy,,, or type. Form designed for use on elif (12-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 /> C', is not required by Federal law.
<br /> WASTE MANIFEST e, I ; of
<br /> 3 Generators Name and Mailing Acicli ess A. State Manifest Document Number i+k,{�a'� ,� r;
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<br /> h �.'f rN tT,; `Lai. +_t !�.� B. State Generator's ID
<br /> `4. Generator's iPhone
<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved]
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<br /> t iD ia�.: i Ilkitair�'{Y�a'.�S �n1.)41 ,�.t
<br /> . Transporters Phone �
<br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.]
<br /> ^'k'}Q F. Transporter's Phone
<br /> f'`w..U 9. Designated Facility Name and Site Ac dress 10. US EPA ID Number G. State Facility's ID
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<br /> fflqi',,X.1tt DDFFi'bf. f.L+7CS a��Y11L.:f�.� iR H. Facility's Phone ^,
<br /> O s.,i��pa?s �.t1:'i •°.C�6 71d .•':� :! ti l) W t% t
<br /> Q , 12. Containers 13. Total 14. Unit
<br /> 11. US DOT Description(including Prone Shipping Name,Hazard Class,and ID Number)
<br /> r�`�,ti�U No. Type Quantify WI/Val I. Waste Number
<br /> state
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<br /> r; ,;,, 1 EPA/Other i a
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<br /> N 6. State
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<br /> R EPA/Other
<br /> `7 A C. State
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<br /> R EPA/Other
<br /> LU d. State
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<br /> U EPA/Other
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<br /> N 1 Adcli Tonal qe.cripti s for Materials L• edAbove,,.. ,,., K. Handling Codes for Wastes Listed Above
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<br /> 0 15. Special Handling Instructionsand Add tional Information
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<br /> :j 16. GENERATOR'S CERTIFICATION: I her 16y 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 r pacts in proper condition for transport by highway according to applicable international and national government regulations.
<br /> 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 /> practicable and that I have selected th rractica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
<br /> V) and the environment;OR,if I am a 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. 1
<br /> r Printed/Typed Name Sign§ttjrd y ..,. Month Day Year
<br /> Z 1 + t �TMl l $ $ IiF "7
<br /> T 1 T Trans orter 1 Acknowledgement of Re i t of Materials
<br /> Printed/T pad Name' Signature Month D
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<br /> .� a Year
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<br /> U_ p c i 18. Transporter 2 Acknowledgement of Ret of Materials
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<br /> T Printed/Typed Name Signature Month Day Year
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<br /> N R
<br /> U .19. Discrepancy Indication.Space .. _. ......_ - -
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<br /> 20. Facility Owner or Operator Certificatio of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name Sign
<br /> tsi Monlh Day Year
<br /> Y '"G� 1/,j-�r •l'i '{.t r�..:..•r / rbv-fir:. '.,`."a',w..........N._.... ,.
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<br /> DO NOT WRITE BELOW THIS'LINE.
<br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.
<br /> DTSC 8022A(1/99) 05-1.5-02PO4:4(gen�atoi��`�'ho submit hazardous waste For transport out-or-state,
<br /> EPA 8700-22 /'V, produce'cdgleted copy of this copy and send to DTSC within 30 d
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