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State of California—Environmental Protection Agey - -
<br /> For MR No.2050-0039(Expires 9-31-991 See Instructions on back Of Page 6. Department of Toxic Substances Control
<br /> Please print or type. Form designed for use on el112-pitch)typewriter.
<br /> Sacramento,California
<br /> UNIFORM HAZARDOU I. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> WASTE MANIFEST P. is not required by Federal law.
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<br /> 3. Generator's Name and Mailing Add ess to l < !. .. Ls j::.L..l... A. State Manifest Document NumberVia,
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<br /> A ,ny.9].• .....,.. ";r 4. B. State Generator's ID
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<br /> rn A. Generator's Phone 4-40'.4 s .. t
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<br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.]
<br /> O - D. Transporter's Phone
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<br /> co '-9.Transporter 2'Cd-by Name' - � � - 8. US EPA ID Number E. State Transporter's ID[Reserved.]
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<br /> -� F. Transporter's Phone
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<br /> 9. Designated Facility Name and,Site A dress 10. US EPA ID Number G. State Fqcili ';.(D,.,
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<br /> t i {:"+ +,�Rf:3 _': 1,.:39!';,�(::i H. Facility's Phone
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<br /> Q12. Containers 13. Total 14. Unit
<br /> V 11. US DOT Description(including Prop Shipping Name,Hazard Class,and ID Number) No. Tye Quantity Wt/Vol I. Waste Number
<br /> Z a <f t .f. .(JI IC,f..i Z 121 IL ",: i-_.f.{;;11.,l t'1.}: I`41. 1 ''y <.� ; �., State
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<br /> y,�; f ,t-q G•aA tF.., EPA/Other
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<br /> R EPA/Other
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<br /> R EPA/Other
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<br /> V EPA/Other
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<br /> V) J. Additional Descriptions for Materials Li ted Above K. Handling Codes for Wastes Listed Above
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<br /> Q 1,5.i,Spscjgl HpgOlin Instructions and Ad itional Information ;- Lj
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<br /> J 16. GENERATOR'S CERTIFICATION: I he by declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified,packed,
<br /> < marked,and labeled,and are in all r spects in proper condition for transport by highway according to applicable international and national government regulations.
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<br /> IF I am a large quantity generator,I 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 t 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 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. e,
<br /> r Printed/Typed Name Signature. 1.;.. `� - - Mont)},.- Day-, Year,,
<br /> w T 17. Transporter 1 Acknowled ement of Re ei t of Materials
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<br /> w p Printed/Typed Name j Signature r i sw. .. Mont�l,. ray-•1 �Year..h
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<br /> wg 18. Transport r 2 Acknowledgement of Rec ei t of Materials
<br /> R Printed/Typed Name Signature Month c.Day Year
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<br /> V 19. Discrepancy Indication Space
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<br /> i I 20.jacility Owner or Operator Certificatio of recei tioF hazardous materials covered this manifest except as noted in Item 19.
<br /> T PriiAtteed/�yped Name Signature l f A � ontfy.» Day j Year
<br /> Y it !� r� / 1�•t jC.�•�:r�'�+' {,,:1 ;������ ; ��•'i!.�,'�,�i,/i.•..����� �.L�; ';fir X'...e�;��`t
<br /> y Dk NOT WRITE BELOW THIS LIN .
<br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.
<br /> TSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state,
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<br /> LEPA 8700-22-: produce completed copy of this copy and send to DTSC within 30 da s
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