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State of California—Environmental Protection Agen y <br /> Form Approved OMB No.2050-0039(Expires 9-3 -99) See Instructions on back of Page b. Department of Toxic Substances Control <br /> &a&%*'W ^,r type. Form designed for use on eli (I 2-pitch)typewriter. Sacramento,California <br /> UNIFORM HAZARDOU <br /> FlGene­,,r�'�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 Add ess - ' = '- A. State Manifest Document Number <br /> O B. State Generator's ID <br /> sr'1 4. Generator's Phone(::::.(.:ru) 4 t - ':..I`• m rC''"i fJ-] .t3'`':`r <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved] <br /> cph <br /> o D. Transporter's Phone _ <br /> ao 7. Transporter.2 Company.Nome.. ... 8. US EPA ID Number E. State Transporter's iD[Reserved] - - -- - -- <br /> a�J F. Transporter's Phone <br /> J <br /> 4w esignyted Facility Nome:andSitaA d�es�s 10. US EPA ID Number G. State Facility',LID. <br /> � <br /> A `?`:`' i i f "' J,3 tx:, ty; <br /> .� ';� c)i.)'.l r_2 �+ H. Faah s Phone <br /> dy ��I.7 <br /> L r O _ .. <br /> V—g J 12. Containers 13. Total 14. Unit <br /> .��-f7,U 11. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> stare <br /> I,fi]"'N•l :-t.'�'i: {`+Ifi.I.{.itCy Li Ca�. •P`t g <br /> 3 G S�. 1 1... i1U h i� DO-39i P {J EPA/Other <br /> L i : /'(._`C i iMl {E.}'� ,. 1.)"D Al( i � y /t ,r".� <br /> c3 N 6. (.•1 1 CE t�"+i`1s'3 i;i l bl k_E 1 A 122)I D, N,1 0. 11.33. ' " , f ✓ stare <br /> co E PK-­TF'G._C-t.h`'t i`�it�x ia_[HA)1'IA1.�r^�i �i I��}.z :" <br /> V R '.�F'C"If '.5'61 ',r.:1. 71„3y, r'r,df=.I.. f D R t+') p i-"��•f If <br /> N 1 jt <br /> A c. State <br /> o T <br /> a0o O <br /> R EPA/Other <br /> od <br /> w d. State <br /> t- <br /> Z <br /> Lu <br /> V EPA/Ot er <br /> Lu <br /> rn 1. Addi'ona De;cri tions'forr rials Lis Above K. Handling Codes for Wastes Listed Above <br /> 6. <br /> d <br /> Lu <br /> w <br /> at c. d. <br /> J <br /> Q <br /> r , :- •- '1 " TR <br /> .Z 15SpecwlHgndlig im ' ifnn; (� o l -.. <br /> Q <br /> Z <br /> uj <br /> ID ;111-E kD <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 are classified,packed, <br /> V <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I 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 /> a practicable and that I have selected th ractica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> a_ p <br /> and the environment;OR,if I am a sa I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O _.Available to me and that I can afford. I� <br /> /"� 's r: ' o r <br /> Printedly,Ped Namer' Signatyre� ' � � t l� 'Roy'v Year I /y <br /> Z f i i A: `S ! '+_ 1 s "1, �'-.`^' t �i :�1� �. J 1�! _ !t r '! ( - ��'al f� fes• 4yi,.,.. <br /> T 17:-'frons orter 1 Acknowled ement of Rec i t of Materials <br /> Lu oc p Printed/T%ped Name yJj ++ % Signature ---I •'' - Month Day^1 Y117r <br /> Lu P _ . <br /> w0 18. Trans orter 2 Acknowledgement of Rec i t of Materials <br /> _7 <br /> R Printed/Typed Name Signature - Month Day Year <br /> T <br /> w E <br /> N R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. Facifi Owner or Operator I of r cAi t of hazardous materials covered b this manifest except as noted/i Item 19. <br /> T Print$d/ ped Name j $igneture.% � ,(� fry onth •Day _y,., Year _ <br /> 1 j-''i� ,� f //� �.f (✓ )'`w 1 /f �c /. r.�� t .+t /� �� 1.4 <br /> fr, <br /> JJ�I ,,DO NOT WRITE BELOW THIS FINE. 7 - <br /> Yellow: T5DF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/991 (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-220425-02'r01 : 17 RCVD produce completed copy of this copy and send to DTSC within 30 days. <br /> , <br />