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State of Califon.a�e:,,u,�mental Protection Agenc _ Form Approved OMB No.2050-0039(Expires 9-3 99) See Instructions on back Of Page 6. Department of Toxic Substances Control Please print or type. Form designed for use on elite(12-pitch)typewriter. Sacramento,California UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page I Information in the shaded areas WASTE MANIFEST is not required by Federal law. of 3. Generator's Name and Mailing((Adttdr ss A. $tate Manifest Document Number r /wa,�`'`�' ,,�, J.A w\. '7':l :.R 0101t. .. bs,Sww V 1� t�> rda O i`_!I�{ _ B. State Generator's ID LO 4. Generator's Phone( ] 1`f / JL1 N 5. Transporter I Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] W1 cp i O ... - ::..,.. D. T ransporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] J QF. Transporter's Phone U 9. Designated Facility Name and Site Ad ress 1 10. US EPA ID Number G. State Facility's ID 7 Z .. _ ... ,.. .Y _ •t 'atr - ') H. Facility's Phone LOO yQ 12. Containers 13. Total -14.Unit ' 1 1. US DOT Description(including Proper Shipping� Name,Hazard Class,and ID Number)U No. T pe Quantity Wt/Vol I. Waste Number Z a. State 2 (t' i..ff i;! L-..1-NIr N In C,0t°rt:`0U)hllD! t t T I ;NO1, UEl J 01' L`Ifi :..) il:tY t 1z G.i i ).) ; EPA/other 3 G +lt) •'s !�'AR PARTE 1 3 E)1 IEfZ :aCJI_!wf .it! 1 tr . Z. v E ,:_., o N b. state co co E v R EPA/Other V A c. State o T � O R EPA/Other Lu d. State Z w U EPA/Other Lu IF, _ N J. Additional Descriptions for Materials List id Above K. Handling Codes For Wastes Listed Above Z p a. b. IL w w J Q ~ 15. Special Handling Instructions and Addi Tonal Informatio -' Q Z Lu = c 16. GENERATOR'S CERTIFICATION: I her y 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 ore in all re pects in proper condition for transport by highway according to applicable international and national government regulations. IF I am a large quantity generator,I c 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 a practicable and that I have selected th racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health N 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 available to me and that I can afford. O y. Printed/Typed Name ` / Signature 'J Month Day Year Lu B 17. Transporter 1 Acknowlecl ement of Rec i t of Materials -•' / �"` w R Printed/Typed Name Signature /�,� �,/ Month Day Year Lu S :/� `3.*Sr•.+G`l,J'Y;!' .i.� 7 �, J(("rte /�1•,��• .a+'�rr'-..Jr•�-9 L--_� <,_._ �..._._ .? t_� y-.'t 1 u. 0 18.'Trans'orter 2 Acknowled ement of'Rec i t of Materials O T Printed/Typed Name Signature Month Day Year w E V) R (aj 19. Discrepancy Indication Space Z F A C L .( 20. Facility Owner or Operator Certification of receipt of hazardous materials covered'b :this manifest except as noted inAm 19. s�p.�ed Name Signatule ,� �� MS'th Day Year, �Y?' �F =rT f. ! '''`_` Db NOT WRITE BELOW THIS LINE. Yellow: TSDF(Gen SENDS THIS C 5 d e I_. DTSC-;,8pQ2A>�1/.g-91_ (Generators Who subr�ii za dou e o i s vf-of-slate, EPA:B6W Hiw C:11 Pr412:"' produce completed copy s c a 5 t within 30 days.)