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State of California—Environmental Protection Agency Form A r_ OMB No.2050-0039(Expires 9-30-9 ) S@@ IIIStrUCtlOr15 On b4CIC Of ^^e 6. PI �c not or e. Form designed for use on elite 1 P Department of Toxic Substances Control 1� type. 9 ( -pitch)y sr. Sacramento,California UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No, 2. Page 1 Information in the shaded areas is not required by Federal law. WASTE MANIFEST of 3. Generator's Name and Mailing AddressA. State Manifest Document Number _ 27 ��5v. O B. State Generator's ID Lr)LO ... ., ., 4. Generator's Phone( ',J 4i",' N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID(Reserved.) V) 00 O D. Transporter's Phone O 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.) 0__ F. Transporter's Phone —iU 9. Delignofed Facility Name and Site Addre is - 10. US EPA ID Number G. State Facility's ID ..,Z Ui4i fqO m}t�1,t {T i} 3 }i .}J-), {3,r H. Facility's Phone 00 J 11. 12. Containers 13. Total 14.. US DOT Description(including Proper Sh pping Name,Hazard Class,and ID Number) Un V it � No. Type Quantity I. Waste Number = a. I_i�,a'.rs'1T•��1 3f,.P, WASTE., f__.i.�.�flJ i, N, t.1. :J. State —AS" S ,.t _tf`.' '., ti •y f 9. 17 h� l i EPA/Other i 3 t a ; t"^! L t t 1; ! +, I E _k:: i i3 ' sl4k :i':i(1't. —.psi_.! d J 0o N b. Stale 00 000 E 4 R EPA/Other v A o T C. State m O R EPA/Other LU d. State t— Z LU U EPA/Other LU V) J. Additional Descriptions For Materials Listed k6ove K. Handling Codes for Wastes Listed Above Z O a. b. w _ C. _ d - J Q QZpecial Handling Instructions and Additio al Information + .. f +. l , 15. 5 ,. " Z ,{_i �y, ��-., i^'f J i.. .. ..a..,l ).,�:_ ..i :.N '..tJ 'tt� ��tli 4'�T EV9 S, 'NZ`— w 16. GENERATOR'S CERTIFICATION: Thereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, Umarked,and labeled,and are in all respe is in proper condition for transport by highway according to applicable international and national government regulations. J If I am a large quantity generator,I certilK 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 practicable and that I have selected the p octicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health U) and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is cle available to me and that I can afford. 0 >_ Printed/Typed Namer ! Signature "? ' Month Day Year i tu.t T 17. Transporter 1 Acknowledgement of Receipi of Materials w A PrintedA ed Name Signature _ nth Day Year 11 / y w F l i'/ A 6'):'?� f.^✓' �_3 L. "� C i� sir^"1� '� • ./ F�M,01istiJ `` U_ 0 18. Transporter 2 Acknowledgement of Receipt of Materials T Printed/Typed Name Signature' '—� Month Day Year LU E V) R Q V 19. Discrepancy Indication Space •'�" •'�.,, - A - L 20. FacilityOwner or Operator Certification of receipt of hazardous materials Covered b this manifest Ocie t p9 noted in Item IV. TPrinted/Typed Name ) r, T - Signature ` is ! �' Month Day— Yea ( DO NOT WRITE BELOW THIS Likt. L t Yellow: TSDF SENDS THIS COPY TO NRA R E'1�V�3 (Generators who submit hazardous to for transpoRdul-.Ue, EPA _8700--802 >22 produce completed copy of this copy and send to DTSC within 30 days.) EPA � —-� '•-`- ='�'''