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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 Subonces Control <br /> Please print-or type. Form designed for lit 12-pitch)typewriter. Sacramento,Califrnia <br /> UNIFORM HAZARDOU 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded oras <br /> is not required <br /> WASTE MANIFEST - of by Federal law. <br /> 3. Generator's Name and Mailing Add ss J `. A. State Manifest Document Number , <br /> 2'10 83 <br /> O B. State Generator's ID <br /> LO Lo ... _ ._.. - .. <br /> A. Generator's Phone( '] - •. <br /> N 5. Transporter 1 Company Name 6. US EPA 1D Number C. State Transporter's ID[Reserved.] <br /> LO <br /> op <br /> O D. Transporter's Phone <br /> -�W a0 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> QF. Transporter's Phone <br /> 9. Desi noted Facib Name and Site Ac dress.. ` 10. US EPA ID Number G. State Facili s ID_. <br /> � O H. Facility's Phone <br /> Q 12. Containersflotal 14. Unit11. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Number) 12. Typetity W. Vol I. Waste Number <br /> a. StateG �1i. + EPA/Other <br /> E <br /> o N b. State <br /> 00 <br /> ao E <br /> R EPA/Other <br /> V A <br /> o T c. <br /> State <br /> m O <br /> R EPA/Other <br /> d. State <br /> Z <br /> W <br /> U EPA/Other <br /> W <br /> v) J. Additional Descriptions For Materials Lis ed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> O a b. <br /> v. <br /> w <br /> W <br /> c. d. <br /> J <br /> Q <br /> Z <br /> O '15.. Special Handling Instructions and Add tion.)Information.. - - <br /> Q <br /> Z <br /> W <br /> 16. GENERATOR'S CERTIFICATION: I her by declare that the contents of this consignment ore fully and accurately described above by proper shipping name and are classified,packed, <br /> Umarked,and labeled,and are in all r pects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If l am a large quantigenerator,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 It(ave selected th racticable method of 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 <br /> I quantity generator,I have made a good faith effort fy-minimize rqy waste generation and select the best yraste management method that is <br /> available to me and that I can afford. —•� r <br /> O <br /> y Printed/Typed Name t Sign rQ fir' �/ Month Day Year <br /> W TR 17.-.Trdrfs orter 1 Acknowledgement of Rec i t of Materials <br /> L7 p Printed/T ed ame' Signature. J Month Da Year <br /> w R yP g f .' - y-. <br /> v �l- ,/,i(i�i% !/ 1 <br /> i - ' ;n <br /> 0 18. Transporter 2 Acknowledgement of Rec iipt of Materials ' <br /> O R <br /> T Printed/Typed Name Signature Month Day Year <br /> Lu E <br /> N R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certificatior of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T 'F rtnf c[�Typed Name .,,1 'f Signotur�- X, Month, <br /> Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THISJMY T� V�fq 30 DAYS. <br /> DTSC 8022A(1/99) (Generators w' ha e port out-of-state, <br /> EPA 8700-22 produce comple ed op of DTSC within 30 days.),..a <br />