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' 51111,1 of California—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039{Expires 9 30 991 See Instructions on back ofQ e E1. <br /> Please print or type Form designed For use an elite(12 p,tchl typewriter P 9 Department of Toxic Substances Control <br /> Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> WASTE MANIFEST r is not required by Federal law <br /> Page <br /> 3 Generator s Name and M11dmg Address <br /> f=`l?`,(A;Ut1N11MAI i! I A Stale Manifest Document Number <br /> 20265365 <br />' L0 (_ i ?: ACII K A VI Y r 1 �11-'K1 ON r A 4 j��lJ 9 x� B State Generator s ID <br /> to 4 Generator s Phone { Itt' i <br /> CV 5 Transporter 1 Company Noma 6 U5 EPA <br /> to ID Number C State Transporter s ID(Reserved I <br /> CP <br /> O iif <br /> As On t 1 �� �x ri � r D Transporters Phone <br /> 7 Transporter 2 Com an Name / 12691667 <br /> P P Y 8 US EPA ID Number E State Transporter s ID(Reserve j <br /> ,^J <br /> W a F Transporter s Phone <br /> V 9 Desr hated Facility VName and Srte Address <br /> � 10 US EPA ID Number G State Fauiity s ID <br /> z -?4 34l A) ALIO SNI)i I it 1 <br /> INC <br /> H Facility s Phone <br /> �� t;l� N `;I VIN, ;'� NV lil�fl2�i <br /> fqj�V1 1 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) ntainers 13 Total 14 Unit <br /> p�,} Type Quantity Wt/Vol I Waste Number <br /> ° BION Tat.SiA I Is�+r7.r M jOLIT i WA,' I I I_1()U!!l State' 221 <br /> G 0 {I A AIf R) <br /> 3 EPA/06er <br /> cN E b <br /> � <br /> E state <br />' -q R v EPA/Other <br /> A <br /> C> T c State <br /> ao O <br />' R EPA/Other <br /> Z d State <br /> Z <br /> w <br /> U EPA/OTher <br /> J Additional Descriptions for Maferipfs Listed Above K Handling Codes for Wastes Listed Above <br /> a a 6 <br /> V) A WA I trl--i! <br /> LUa <br /> J [ d <br /> a <br /> Z 15 Special Handling Instructions and Additional Information <br /> 0 <br /> Z k 141 Nt f r ON I ria i <br /> ',( It Ir r, If I <br /> Q16 GENERATOR 5 CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately descrr6ed above by proper shipping name and pre classified packed <br /> U marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br /> J <br /> If I am a large quantity generator I certify 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 <br /> practicable and that I have selected the practical method of treatment storage or disposal currently available to me which minimizes the present and future threat to human hapith <br /> N <br /> � and the environment OR +f 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 <br /> O available to me and that i con afford <br /> r Printed/Typed Nam <br /> Signature Month Day Year <br /> U <br /> Z <br /> 3 T 17 Tran orter Acknowledge;%int of R e+ t of Motenals <br /> R <br /> LL, <br /> t, Printed/Typed Name Signature N ` �L g <br /> w S Y!� / f -� / l /' J ���......r Doth Day- I J,)ek <br /> P , <br /> W p 18 Transporter 2 Acknowled ement o ecei o`f aterrols <br /> 0 T Printed/Typed Name <br /> r w E SrBhoture Month Day Year <br /> < <br /> R <br /> a <br /> U F 19 Discrepancy Indication Space <br /> Z A <br /> I <br /> 1. <br /> { 20 Focdr Owner or O orator Cnrtifrcation of,ecei t ul hazardous mateu 11 covered b this mamfest except as noted in Item 19 <br /> j Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> 1 DTSC 0 (1/99) <br /> EPA 87700--22 Yellow GENERATOR RETAINS <br />`I <br />