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State of Cal ifornia—Environme�ntal��rotection Agen y - Form Approved OMB N6-2VW0039(Expires 9-30-99) See Instructions on back Of Page 6. Department of Toxic Substances Control Please print or type. Form designed for use on elil 112-pitch)typewriter. Sacramento,California UNIFORM HAZARDOU 1. Generator's US EPA ID No. Manifest Document No. 2. Page I Information in the shaded areas is not required by Federal law. WASTE MANIFEST of 3 Generator's Name and Mail mg Addr ss A. State Manifest Document Number ? LJa, ri;'1s}:1�r r "1 1�L) �.ntt•,a . . .. t'�`1 O �,i'`S fQ Yi r3L.t1't A••d.:;. B. State Generator's ID LO W) A. Generator's Phone( 2C)9) _rk l-1 t. CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.) h O' �..i;.t, i7.t � ta?_......I.:.f i ;..`,.... .mss+._,+ t .I�;. - .",.l t.�:.;1.' _`.."..! D. Transporter's Phone aD 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] Q F. Transporter's Phone V 9. Designated Facility Name and Site Ad Jress t '+t - 10. US EPA ID Number G. State Facili s ID - i Z cX .+.,. I,:,._)s• i 1.: .. H. Facility's Phone ., .. u 916 3es.'1 f Q 12. Containers 13. Total 14. Unit n - 11. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Numberl No. Type Quantity Wt/Vol 1. Waste Number Zo. State = r.4AZAR:DLril''3 WAC 'E:, si. c.. ; . ..:i EPA/Other G BR�KL ) I QE N b. State co E -4 R EPA/Other 04 A C. State o T m O R EPA/Other W d. State t— Z W C.J EPA/Other w N J.-Additional DescriptionsforMaterials Lis edA.bove- �-,:_1.. - - - - K. Handling-Codes for Wastes_Listed Above- - Z 0 a. b. CL tq W ad C. d. J Q Z -e :f:,r"i.:^i 3:$. is+.i `i 'a,i..1'.s O 15. Special Handling Instructionp and Add1 conal Information. Q ..':•o 1Tt C'i'.1PC _ _ 1 J} {W i i4.L s.J :. -N 15 t:...` ,.F .:)',.lel!_' C.l S„1= CARR'.f_cAL' 4•f_ s'AI'+ . Z LU —Ji 16. GENERATOR'S CERTIFICATION: I her by declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, Vmarked,and labeled,and.are in all re pects in proper condition for transport by highway according to applicable international and national government regulations. J —+ If I am a large quantity generator,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 CL practicable and that I have selected theracticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environment;OR,if I am a sm I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is a available to me and that I can afford- 0 } Printed/Typed Name Signature- ' - ,,� . Montt, )Day Year Z (e W T 17. Trans oiler 1 A`cknowled ement of Ret!ipt of Materials %'r - � R LU Printed/Typed Nam -�„ Signature FnMo nth, Day Year W - P .'.s�1'n. � �) - r sL 0 18. Trani orter 2 Acknowled ement of Rec pipt of Materials � T Printed/Typed Name Signature Month Day Year T W E 0 N R Q V 19. Discrepancy Indication Space 2 12:44 1 20. Facility Owner or Operator Certificatiori of recei pt of hazardous materials covered by this rA6nifest except Zts noted)t,it..19/ T Printed Typed Name Signature tpi �\ 7_11. onth Day(�' Year . 1 4 •y � 1 ! t � ' ! 1 DO NOT-WRITE I466 T IIS LINE.' _) Yellow: TSDF SENDS��Y TO GENERATOR WIT IN 0 DTSC 8022A(1/99) (Generators who submit hazardous waste for tra ort out-of-st ■i� EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)