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Slate of California--Environmenlal Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 99) See Inslruchons on back of page 6 Department of Toxic Sv6slonces Control <br /> Please print or type form designed fowse an e)de(12 pitch)typewriter Satramenlo Cahformo <br /> UNIFORM HAZARDOUS I Generators US EPA ID No Mgnrffps DoCumgnl,No 2 Poge 1 is o t aoicinrequired <br /> a he shaded areas <br /> w� �D \V'1/f /// 1/y/ / anal required by Federal low <br /> WLNoMdyd <br /> MANIFEST 4of r <br /> 3 G rr to ylpII ddresy., A State Manifest Document Number//��� ,K��C.`/� o,-% <br /> Cp01a� �5ul�r S�Ua <br /> 97384 <br /> oQa i;"plNr nt, 4 YY'?3 B J StelaLG�nara/ 1 IQ U �/ e �_Jl to A Generolor's P6ane( IWO )7-77'—��� CT�N• Ccs `+C7�5�Z]iv, 17 Hf T T a i{ <br /> IN <br /> sN 5 Tr a parser 1 Company Name 6 US EPA ID Number C State Transporter s ID <br /> S o�� �r �`t�l�e TransporlarsPhan e ���i 9's�E;,i, <br /> 7 Teansporler 2 Company Name { (� 8 US EPA ID Number E Slate Transporter s ID - `t <br /> J F, Transporler's Phone <br /> V9�asig3nafed Faali Nome a Site A¢dddreu I0 U5 EPA ID Number G Stole Facilely s Ip <br /> a r 7 pS1 tFJ �i (t' cLUvevy romParT� �f�c f� <br />,« �3 C- +t��g r,dl l CL 5--t- Hi Fa �V one�3�l— <br /> o ©a(cfcxc�dt C, 9yba7 c � c v o 6 ! 7 �/ <br /> 12 Conlainers 17 Total I A Unit <br /> I 1 US DOT Descnplion(including Proper Shipping Nome Hazard Class and 1D Number) <br />�UjNo Type Ouanldy WI/Val I Waste Number <br /> ° NDN State <br /> T ' <br /> ri L 1'9 t c C ( '� 01, { , I �� , / C7' EPA/Other <br /> 1= 99 <br /> 6 Slate L <br /> C14 N <br /> ado E EPA/Olhors'`i sw <br /> R s.` <br /> el <br /> a A c Stole <br /> T t <br /> W O EPA/Other <br /> 0 R <br /> '7a <br /> ii d Stale <br /> Lu EPA/Olher 4 r 1,` <br /> V <br /> KJ i Addi)T hid Ilodf t rip�iif►�eIs66v+'�}�i,c�s' '�w.t 4 4;s>K�f1 b rt ;4� c1''�`7)i +�L )aITt= r K JHandlin�Codas for Wastes Listed Above <br /> 6 <br /> H F '' lcyf.11 �4 <br /> r j <br /> � , +�.�`� <br /> wnH } s i <br /> Z 15 Special Handling Instructions and Additional Information <br />� If <br /> UI PaY- gIDV• S /We ' 9e� C[r 017� -r 3a P�rX <br /> r >�r ••�' <br /> Z <br /> / 7/ G 2-9 s rd�� 7<�•� <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this constpnmeni ore lolly and occvrotely described above by proper sb+p tno name and are classified packed <br /> Jmarked and labeled and are in all respects in proper condition for transport by highway according to oppltcable international and notional government regulaltons <br />—i <br /> If!am o large gvonsiy generator 1 terrify that I have a program m place to reduce the yalume and toxicity of waste generated la the degree I hove determined to be economically <br /> 1 practicable and that ITselected the racticable method of treatment storage or disp6sal currently available to me which min m zes the present and future threol to human health <br /> n <br /> oast the environment OR if I am a small quantity generator I have mode a good forth a ort to minimize my waslh on and scietl the best waste manarjemcnl method Ihat is <br /> available to me and that I can afford / , <br />}. Printed/Ty�ed-iJ 71i JDLor <br /> T 17 Transporter 1 Acknowledgement of Recei TIP of Materials <br /> R <br /> E Prrt d/Typed�Norme Sisrf�v e r/ _ nth_ oyes <br />:Es <br /> t 0 18 Trans oder 7 Acknowled emenf of Receipt of Materials <br /> R Prsnied/Typed Name Signalwe Month Day Year <br /> IT <br />,a c <br /> n R <br /> j19 Discrepancy Indication$pace <br />� F <br /> A <br /> C <br /> I <br /> k 20 FocililX Owner or Operator Certification of receipt of hazardous materials covered by this mantles)exce l as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> r <br /> 22A (4/97) <br /> Blue GENERATOR SENDS THES COPY ]O DISC WITHIN 30 PAYS <br /> 0-22 <br /> OTSC B0 <br /> EPA 87022A 1 To PO Box A00 Sactomenlo CA 95817 0 100 <br />