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State of California—Environmental Protection Agency <br /> Fo,•^° --�--J+OMB No.2050-0039(Expires 9-30- 9) See Instructions on back Of Page b, Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite 12-pitch)typewriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Addres A. State Manifest Document Number <br /> 101483 . <br /> O <br /> h -- B. State Generator's ID <br /> _- .. ... <br /> A. Generator's Phone .:CN <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> Qu <br /> O D. Transporter's Phone ] <br /> O <br /> 0 <br /> 7. Transporter 2 Com�Name8. USEPA ID Number E. State Transporter':ID[Reserved.] <br /> yd J <br /> coQ F. Transporter':Phone <br /> V 9. Designated Facility No <br /> me,and.SiteAddr ass '`' ' 10. U$EPA ID Number G. State Facility's ID <br /> rs"�`ICe <br /> O rft 't✓il✓'Y;�-(: ;!1 <J H. Facility's Phone <br /> - <br /> " 1 1. US DOT Description(including Proper 5 i m Name,Hazard Class,and ID Number 12. Containers 13. Total 14.rUnit <br /> V P ( g P PP g [ No. Type Quantity Wt/Vol I. Waste Number <br /> Z a. <br /> _ - <br /> State <br /> 3 Gf EPA/Other <br /> N E �o f' .to, � .� <br /> o N b. State <br /> co E <br /> �7 R EPA/Other <br /> v A <br /> o T ` State <br /> ado O <br /> R EPA/Other <br /> Lu d' <br /> F-w- State <br /> Z <br /> w <br /> V EPA/Other <br /> w . <br /> ZJ. Additional Descriptions for Materials Lists Above K. Handling Codes for Wastes Listed Above <br /> O a. b. <br /> a <br /> N <br /> Lu <br /> c. d. <br /> a <br /> Z <br /> 0 15. Special Handling Instructions and Additio al Information <br /> Q <br /> Lu <br /> j'S - <br /> J 16. GENERATOR'S CERTIFICATION: I hereladeclare that the contents of this consignment are fully and accurately described above by propershipping name and are classified,packed, <br /> Umarked,and labeled,and are in all resp cts in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I am a large quantity generator,I cerci 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 the p acticable 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 small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> ae <br /> ae available to me and that I can afford. " <br /> V Printed/Typed Name - Signature - Month Day Year <br /> Lu J <br /> T 17. Transporter 1 Acknowled ementoT"Rece- of!Mateiiah <br /> Lu Printed/Typed.Name _ ,- Signature <br /> - - - <br /> R- r 9 ,.,.,rl -,y_• Month Day - Year <br /> Lu P r ._.✓r/,�i�;�.�,.'� ;_ .-�.✓ �,. -�}�r//��/r„r'C .+�' '"' �,''• �,aA�,".:iz„ .� �J �� <br /> w B 18. Transporter 2 Acknowled ement of Recei of Materials <br /> R Printed/Typed ed Name 'g Month Day Year <br /> T YP Signature <br /> w E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z C <br /> 20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this mbni est exc 't as noted in Jte •19. i <br /> T ,'Printed/Typed Name Signature ,�\e j <br /> ie A <br /> .., <br /> D{O <br /> NOT-,WR ITE BEIbW THIS LINE. <br /> Yello-: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) RECEIVE FEB 112�l3 (Generators who submit hazardouswastefor transport out-of-state, <br /> EPA 8700-22 produce completed copy of this co and send to DTSC within 30 d <br /> n <br />