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State of California—Environmental Protection Age cy ;' ,.2•.. l)J.
<br /> Form Approved OMB No.2050-0039(Expires 9- 0-99) See Instructions on back of page 6. Department of Toxic Substances Control
<br /> Please prin�Form designed for use on efi a(12-pitch)typewriter. Sacramento,California
<br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> UNIFORM HAZARDOU :'I is nottequired by Federal law.
<br /> WASTE MANIFEST of '
<br /> 3.,-Generator's Name and Mailin Ad ress t r -•s A. State Manifest Document Number �**�
<br /> 1 I.�rlX ;.::' J 1=<fii...t!` pfd fs �1 �R�'L�2 dL
<br /> O '-;='„ll F Fglvlt�l'sj {.,A iIi'•.:1i:J..S'""�J''?O tit'r� B. State Generator's ID
<br /> LO 4. Generator's Phone(2{:)5ii) -4'4'"'40�1.4 �-i`''%:'Y�6 .,11119?
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<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
<br /> 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Transporter's ID[Reserved.]
<br /> F. Transporter',,Phone
<br /> :Q fDles�gnotetd,F nLI'tyiW `'. 10. US EPA ID Number G. State,Fac -39,
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<br /> = 9P-4.t�.'S., C A i�r 53�'2 r`'1 f�I�..1�'s.,�',.[.?t"f:�r•') H. Facility's Phone 209
<br /> 12. Containers 13. Total 14. Unit
<br /> Q 11. US DOT Description(including Prop r Shipping Name,Hazard Class,and ID Number)
<br /> Type Quantity Wt/Vol I. Waste Number
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<br /> 3 G 1':RlG#1x G-D 6. ',7##/G= L-. t 17�?t,�'!, ?'OI.8, D)39, :.fit 40) EPA/Other l:!ia0:1,
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<br /> v R L;.f?c?t#'v23 6. 7L_X313/GAI._ (,.3Cft 39.;CN / / �, J EPA/Other DO 3{I
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<br /> Z J: e,ddifionaj`D.ee cTiputfoni(Ir,A p}grials L'to Abo ! K. Handling Codes for Wastes Listed Above
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<br /> 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 /> Vmarked,and labeled,and are in all r spects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> If I am a large quantity generator,I ertify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically
<br /> I and that I have selected t e practicable method aF treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
<br /> 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 /> 0 available to me and that I can afford.
<br /> } Pr' te�/Typed Name Sign afu .h Mont ay Year,
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<br /> T -T7. Trans ort r 1 Acknowled ement of Re ei t of Materials
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<br /> ` w R Pried/Ty ed rlaf� �„- .-" f { j( �.�,Jfd Signature ,/ /'� �y// !Month ..\Day� Year,
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<br /> 10 1
<br /> LL 018. Trans orter 2 Acknowledgement of Rel ei t of Materials
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<br /> 0 Printed/Typed Name Signature Month Day Year
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<br /> U 19. Discrepancy Indication Space
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<br /> 20. Facility Owner or Operator Certificatio i of receipt of hazardous materials covered:b 'this manifest except as noted in Item 19.
<br /> T Printed'Typed Name , Signature` j I I ,MQntly Day Year
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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) ,�.� _ _ (Generators who submit hazardous waste for transport out-of•stote,
<br /> EPA 8700-22 0 5—2 5—0 2 A s,7 •uJ 1 R i V D produce completed copy of this copy and send to DTSC within 30 days. ^
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