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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 6. Department of Toxic Substances Control <br /> Please print or type. Form designed For use on el i', (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 is not required by Federal law. <br /> WASTE MANIFEST \ f ._j of s <br /> 3..Gfnerptor' Namgand Mallin Add ass A. State Manifest Document Number '�j� t _pry_ <br /> Bev 509 ;{{YSmn 10300 pian Rarfsih7 't.,10468i B. State Generators ID <br /> oV) t: hh tiP M k <br /> 'A A. Generator's Phone( I b" f!�l �1 vi. 4 .t L3 j1011, <br /> S9 '� •s,+ �r <br /> n <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved] <br /> LO <br /> 4'+i1L(a W L17t% A " F � �+ <br /> 31-i 3911D. Trans orter's Phone <br /> o <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> h*.,m <br /> F. Transporter's Phone <br /> U9. Designa}ed Facility Name and Site A dress 10. US EPA ID Number G. State Facility's ID <br /> Q P v 1:'if t )i 3YtisG i) .i}1fJCiTi �i+ ' <br /> ZfMs15c2�1 146,1<Y(a H. Facility's Phone <br /> y wx24-1638 <br /> p f, +5k .kit,44,C+ � 1;];s A i�,` 010 9 45 <br /> $i�J�D <br /> ' 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Prop Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> V <br /> State <br /> ;543 <br /> 2 <br /> G [)Iiespi and ��i3Tf:?C.l�I�,i'r�: -.,� ,� '•,:,r EPA/Other <br /> N E 6. State <br /> o N <br /> a60 E EPA/Other <br /> R <br /> NV A c State <br /> o T <br /> � O EPA/Other <br /> R <br /> Lu d. State <br /> ( r <br /> Z <br /> Lu EPA/Other <br /> U <br /> Lu K. Handling Codes for Wastes Listed Above <br /> Z ��:J ditignal1.9cn lions for Materials Li ted A6ove 9 <br /> Z iCtr , <br /> _ b <br /> a. <br /> [ O wt y, .r'l i o-br t(}ilyt, Ali"Scl 1 ro-.'S% <br /> N <br /> Lu <br /> cc c. d. <br /> Q <br /> Z ] e I lin I 90 o TI l7rmaGoG Number 17t 7T"} ac3 } : sr_ t, s ` <br /> Z }r`�!'�ir Proper Protecn e Equipment Station Address a 300 �Lvr �► �- �� �'�ni��-T <br /> = ER !71. Ezra job n+l;r bar• <br /> t— <br /> 16. GENERATOR'S CERTIFICATION: I h eby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classif ed,packed, <br /> Vmarked,and labeled,and are in all aspects 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 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 a 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 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 /> °C available to me and that I can afford <br /> ti 0 Month Day Year <br /> Printed/Typed Name <br /> Aj <br /> w T 17. Transporter 1 Acknowledgement of R cel t of Materials C e L <br /> R -- - �-' Month Day Year <br /> wA Printed/Typed Name Signature - <br /> ujP <br /> u- 0 18. Transporter 2 Acknowled ement of R ei t of Materials <br /> 1 Printed/Typed Name Signature Month Day Year <br /> Lu E <br /> sn E <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> L ^ <br /> 20:'Facility wner or OOperator Certificati n of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> I <br /> T Printed/Typed Name '. Signature___.__....-;-._-- Month Day Year <br /> DO NOT WRITE BELOW—Mf$ LINE. <br /> 1 Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-State, <br /> DTSC8022A(1/99) produce c6mpleted copy of this copy and send to DTSC within 30 <br /> EPA 8700-22 JJ <br />