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State of California—Environmental Protection Agen y c,
<br /> Form A roved OMB No.2050-0039(Expires 9-3 -99 / J_"'
<br /> per--__ ( p ) See If15tFUCFIOnS Ofl bOC1C Of PO9Q 6. Department of Toxic Substances Control
<br /> Please.pu-nTor�Y�7`e. Form designed For use on elit (12-Pilch)ypewrifer. 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 b Federal law.
<br /> WASTE MANIFEST f . 3.'`64,` '' r° of q y
<br /> 3. Generator's Name and Mailing Add ss PACIFIC BELL A. State Manifest Document Number 1,311826
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<br /> O S"a t. h f^ +, 5 B. State Generator's ID
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<br /> Ln A. Generator's Phone(s�'�9 W'i. x�j ' 'ti k's ;
<br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved]
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<br /> 1Z EMS,7'x. �C""�a,i•.. .:,}'4t ':���a?',; EMS., 1.1140 L '11477[TO3,i D. Transporfer's Phone o •�
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<br /> •_ 7. Transporter 2 Company Name
<br /> 8. US EPA ID Number E. State Transporter's ID[Reserved]
<br /> a� F. Transporter's Phone
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<br /> U 9 Designated Faciliy.Name and Site Ad ress •f bV 10. US EPA ID Number G. State Facility's ID -
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<br /> t,.rJ O h�LC AMCK f L CA 95820 C AOOOO>r 84517 H. Facility's Phone •iy
<br /> �_4 Q 12. Containers 13. Total 14. Unit
<br /> V 1 1. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number
<br /> State
<br /> a t-tA'Z,FAFt•1 OVS WA:t7`E.t LI0VID, del, 0. S. £yl C 134
<br /> 9 t� A3082 Orsi t}.1 x.:1039,, (EMG#,171> EPA/Other
<br /> 3 G AQ;,,.F0k)S �RAKE S V1•',CL}N(8, 3#/GAL.) "'. : (. ;� D039
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<br /> b. State
<br /> eco N USED CLEANING +:+f.�P°PE3�,)N S,, N. O. 1, B. I1, x.3'4
<br /> W E LIG >ykl'D 6BAOT VS-DOT OfUSEDA REGU-LATER)
<br /> vf4vlt1S ADM a EPA/Other"ARTS: WASHER V3LU11014 K$ 3#GA 1A
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<br /> R EPA/Other-
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<br /> U EPA/Other
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<br /> h J. Additional Descriptions for Materials List d Above K. Handling Codes for Wastes Listed Above
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<br /> 0 15. Special Handling Instructions and Addit nal information 0;s'4 1 a?sG�},�5.14
<br /> EMERGENCY 6-977-7777 24HR
<br /> z 'SK AVTHCR Z'ZE.1 'T I FTA l lei AJ CE�9SEO SUB-SE'3UENT :W"ARR I ER, ,A S %%'E CE8SAR�',
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<br /> 16. GENERATOR'S CERTIFICATION: I here declare that the contents of this consignment are fully and accurcrtelyrdescribed above by proper:hipping name and are classified,packed,
<br /> Vmarked,and labeled,and are in all res ecls in proper condition For transport by highway according to applicable international and national government regulations.
<br /> If I am a large quantify generator,I cer ify'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 f ave selected the racticc61e 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 sma 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 /> CX available to me and that I can afford.
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<br /> Printed/T�ped Name; f�. _Signature / Month Day Year
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<br /> O R 3 tans otter'1 Acknow6dement of Recei t of Materials
<br /> _ _w _ S_- P.cjted/Typed14cmne. _ _-.----_ - �...- S8n'ature _ _ - _ - _ _ Month Day Year
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<br /> tL 0 18. Transporter 2 Ackoewled ement of-Recei t of Materials •""`'� /�
<br /> O T Printed/Typed Name" Signature '•t Month Day Year
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<br /> V 19. Discrepancy Indication Space
<br /> • F - 20. Facility Owner or Operator Certification receipt of hazardous moteridls--covered by this nicrnif4st e e t os noted in Item
<br /> T anted/Typed Name SignaTur,� r \ Month Day Year
<br /> Y tib. l J V` n.
<br /> } DO NOT WRITE BLOW THIS-LAE.
<br /> -IlTSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.ti'-�,
<br /> DTSC 8022A(1/99) „tet �V (Generators who submit hazardous waste.for transport out-of-state,
<br /> g'"`"' produ.e completed copy of this copy and send to DTSC within 30 days.
<br /> .EPA B7°°-22 R C E I V E D OCT 2 5 2001 ,
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