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State of California—Environmental Protection Age cy <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 print or type. Form designed for use on efi e(12-pikh)typewriter. Sacramento,California <br /> UNIFORM HAZARDOU 1• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST `Yj, D 7 `` is not required by Federal law. <br /> C.1l.i.•'^ .y ..i of ' <br /> 3. Generator's Name and Mailing Ad resin A. State Manifest Document Number <br /> t �4 7 <br /> B. State Generator's ID <br /> LO <br /> n A. Generator's Phone ( - ,. .'•1-' / i'I ..t 'r ._ .� fir, 0d 1110 19 ., <br /> CV 5. Transporter 1 Company Name 6i US EPA ID Number C. State Transporter's ID[Reserved] <br /> h <br /> O d�'wrY:,.3JS':.::.'P:-'i;i.D L.I:IN)4''T RI: `.. - r, a•'2 ++••�� ry .pv t-. -a aw a -•! D. Transporter's Phone a .�yy+,yy,, 113 <br /> a? 7. Transporter 2 Company Name 8. US EPA ID Number - E.State Transporter's ID[Reserved.] <br /> J <br /> ��--' F.'Transporter's Phone <br /> k Q <br /> *�v' U 9. Designated Facility Name and Site dress 10. US EPA ID Number G. State Facility's ID <br /> .1 E{':01-00 s'COM(R.0I_IN 3f_f`aTRIE..S <br /> M� )fir?L1Rl'{ I7-gS71 H. Facility's Phone <br /> '� Ralrw-+�wtL.Hn aY nr,.r n. i 4 at €� 1� yG'� C' 'a r3 a'1 <br /> W *.r4tit,;v7 inti .. d9 tR ,Y +.w i3 I.f ., :,s C. v ,.• f .+ 3 d..f.,"n�l�.S ii <br /> "U Q 11. US DOT Description(including Propr Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> U No. Type Quantity Wt/Vol I. Waste Number <br /> " <br /> Z CN R�':f�'A HA��rARL;t AUS V13. ::>;TE- SU'l ID state <br /> ~3 CT -MP-','Y <br /> �--r n e " U U 1 7 EPA/OtherG . J a n c <br /> E t <br /> o N b. State <br /> 00 <br /> oo E' EPA/Other <br /> v R` <br /> v A <br /> o T `' <br /> State <br /> C O <br /> R EPA/Other <br /> w d. State <br /> t— <br /> Z <br /> LU <br /> U EPA/Other <br /> w <br /> I Additional Descriptions For Materials Li led Above K. Handling Codes for Wastes Listed Above <br /> Q a <br /> Y j l u. ?... kt,.:f­l-k i-; s :J t.,Prf i t rl't:'i!...-;r t��„.t i y a d. <br /> 0 15. Special Handling Instructions and Ad("itional Informction <br /> S,•}�-E' a.,,.�c� .i_-,�_ 1 ,�rt, i �! / a7,Oc may+ <br /> Z WEAR P;-tOPFR PELwEc nVE lE QUiP(dC;Ni'WHILE:P-ANfai..ING. WEIGHTS ORVOLUMES AFRF APPisOAHVI/ATE <br /> 21 HOM'R EMERGENCY r'N1'F ,C'T`. PACIFIC BELL DISPATCH AES.CTR ria JOB rx 5v77-6 675 JW <br /> �' :%c" i>"ii i T•�•N'; %S-ii 7:r`.1= !tl' :t` -- '" <br /> 16. GENERATOR'S CERTIFICATION: 1 he eby 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 spects in proper condition for transport by highway according to applicable international and national government regulations. <br /> IF I am a large quantiy 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 /> o_ practicable and that I have selected t e rracticable 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 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 /> ac available to me and that I can afford. <br /> O <br /> y Printed/Typed Name Signature I Month Day Year <br /> yv�1- j <br /> tL RT 17. Transporter 1 Acknowledgement of Re ei t of Materials— <br /> y 4 f <br /> w A Printed/Type <br /> )� Name Signattuur/e1 t TO Monthh'7 Day'”' Year <br /> wF 9rydit\t.t- �7 7+�sr._i�I)=wr t G'�L• iL �,'--•.� L- ti T 1_/ / �r� <br /> W 0 18. Transporter 2 Acknowledgement of Ree i t of Materials <br /> Q T Printed/Typed Name Signature Month Day Year <br /> N E <br /> R <br /> V19. Discrepancy Indication Space <br /> Z A a <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certificati i of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name - Signature p Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. ED <br /> Yellow: TSDF SENDS THIS COPY TO GENERAT ITZ)6 IWI <br /> DTSC 8022A fl/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br /> RECEIVED SEP 0 2 200: <br />