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.c_----r- lifornia—Environmental Protection Agen y <br /> Form Approved OMB No.2050-0039(Expires 9-3 -99) See Instructions OEI back OF Page 6. Department of Toxic Su65tonces Control <br /> Please print or type. Form designed for use on eli f 12-pifchJ ypewriier. Sacramento,California <br /> UNIFORM HAZARDOU 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information ritesshaded areas <br /> WASTE MANIFEST is not required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Add ess 1.:_.. A. State Manifest Document Number ,. <br /> 2252 5 ,r <br /> B. State Generators ID <br /> nA. Generators Phone( .. `>) / ^F""�f ti:1. 4. <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID(Reserved.) <br /> h <br /> a0 <br /> O ..; ._. . D. Transporter's Phone <br /> co 7. Transporter 2 Company Name B. US EPA ID Number E. State Transporter's ID[Reserved] <br /> Q F. Transporter's Phone <br /> LOU 9. Designated Facility.Name,on4.ite.A dye{&C '� - 10. US EPA ID Number G. State Faciliy's ID <br /> i i C'x i i •si')? '' 3.° r'iJi'i H. Facility's Phone <br /> UJO <br /> oj <br /> 114 Q 11. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> V No. Type Quantity Wt/Vol I. Waste Number <br /> Z a State <br /> 3 G EPA/Other <br /> o E b. State <br /> co E <br /> R EPA/Other <br /> A c. State <br /> o T <br /> co O <br /> R EPA/Other <br /> Lu d. State <br /> t— <br /> Z <br /> w <br /> V EPA/Other <br /> w <br /> sn J. Additional Descriptions for Materials Li ted Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> O a. b. <br /> a <br /> sn <br /> Lu <br /> c. d. <br /> Q <br /> Z <br /> 15. Special H ndling Instructions and Adc tional Information. - - <br /> Q <br /> Z <br /> w <br /> _ s... .. .... - _ <br /> H <br /> Zj 16. GENERATOR'S CERTIFICATION: I he by 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. all r spects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator,I rtify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> v- practicable and that love selected f practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N <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 /> od available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature - ' ! Month Day Year <br /> w T17. Transporter 1 Acknowled ement of Re ei t of Materials <br /> Lu <br /> I Printed/Typed Name Signature �.. �;,;,i - rrl.%^ Month Day Year <br /> Lu s /f� ,, - <br /> w 0 18. Transporter 2 Acknowledgement of Re,i ei t of Materials <br /> O RT Printed/Typed Name Signature l Month Day Year <br /> to R <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 0 V 10 F'M12:1 3 <br /> 20. Facility Owner or Operator Certificatio of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name ` Signature - f'.t Month Day Year,.•� <br /> Y AJI r! <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: T5DF SENDS THIS COPY TO GENER mei IN DAYS. <br /> (Generators who submit hazardous wase r ns <br /> DTSC 8022A(1/99) produce completed copy o this copy and en to h <br /> EPA 8700-22 <br />