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<br /> State of California—Environmental Protection Age y
<br /> p—r911.1-33
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<br /> Form M6-ViMB No.2050-0039(Expires 9-3 -99) - - See Instructions on back Of Page 6. Department of Toxic Substances Control
<br /> Please print or type. Form designed for use on eli (12-pitch)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 /> s not required by Federal law.
<br /> WASTE MANIFEST of
<br /> -3. Generators Name and Mailing Add ess A. State Manifest Document Number _
<br /> 2 25 Vf :br o�J
<br /> B. State Generator's ID
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<br /> 4. Generator's Phone];.�{•,ir,') -ii(1? "z., ';.i ;+ r.,r '
<br /> CV 5. Transporter I Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.]
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<br /> t{..,,.`c:`.f'-•1 .�, .. ? `.., i.;AL. t ]"�Iv,ti.1Q.�,ulfy .»%! D. Transporter's Phone
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<br /> �^ 7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporter's ID[Reserved]
<br /> CV j:j F. Transporter's Phone
<br /> Designated F ciliy Name and Slip A d ss `' 10. Us EPA ID Number G. State Facility's ID
<br /> Q,'-34 c iO H. Facility'sPhone
<br /> U 12. Containers 13. Total 14. Unit
<br /> 77nn�W.7 1 l. US DOT Description(including Prope Shipping Name,Hazard Class,and ID Number( No. Type Quantity Wt/Vol I. Waste Number
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<br /> V EPA/Other
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<br /> ZJ. Additional Descriptions for Materials U31 id Above K. Handling Codes for Wastes Listed Above
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<br /> 15 Special Han�ling,instrpstions.pnd{4ddi'onal Infgrma�ron " �- �i -- a. .I.... .. . ..>. .. ''i
<br /> 7 `.f t k.h! 'c f L ii"' .'ft7• sn:, -r s
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<br /> Zj 16. GENERATOR'S CERTIFICATION: I here y 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 re pacts in proper condition for transport by highway according to applicable international and national government regulations.
<br /> IFI am a large quantity generator,I ce iFy 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 I have selected th ractica6le method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health
<br /> N and the environment;OR,if I am a sm P quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is
<br /> available to me and that I can afford.
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<br /> Month Day Year
<br /> Printed/Typed Name._ - - - Signature ?
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<br /> R 17. Trans orrer 1 Acknowled ement of Rec t of Materials j
<br /> W � Printed/Typed Name ' Signature .�� „_..- Month Day Year
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<br /> w B 18. Trans orter 2 A Pt of Materials
<br /> O R Printed/Typed ed Name
<br /> T yp Signature Month Day Year I`
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<br /> U19. Discrepancy Indication Space
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<br /> ( 20. Facility Owner or Operator Certification f receipt of hazardous moteriali'covered by this manifest ex/ t as noted in Item 19.
<br /> T Printed/Typed Nomer sig`nature�- ~�.- \ Month Day _ Yegr
<br /> DOS',}OT WRITE.BELOW rtHIS LINE'
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<br /> • Yellow: TSDF SENDS THIS COPY TO`6 ATOR V�TRIte3Q)�
<br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-o-state,
<br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)
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