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r Sacramento,Califo crease print or type. Form designed Tor use on elite(1 -pitch)ty�-writer. 11-11. 0 U �� nia UNIFORM HAZARDOUS erator's US EPA ID No. Manifest Document N 2. Page 1 Information in the shaded areas � is not required by Federal law. WASTE MANIFEST r- A L- o o b l t_ b -r y p 0 0 0 v�. ( of 3. Generator's Name and Mailing Address A. State Manifest Document Number rC.DI rJ TONG A"''�"'�rw^4',VG =.+� =uC 63� s. F� �o�A�, S-r. 2016: 570 5 u Gk. 71-„hl p C-A 9,5�'G J 3 Na� B. State Generator's ID 4. Generator's Phone ( ;-01 �/Y8 /!a� pt[ Perks i N 5. Transporter 1 Company Name N't t p 6. US EPA ID Number C. State Transporter's ID[Reserved.] LO ao �AU:�)PO e T P-T-c 1.J O t?&A(.:-01�T1d1� s r0 C! � 3 S � C7 5 D. Transporter's Phone �Od - 3a � -•14 3a O Oo 7. an Transporter 2 Com N P Company B. US EPA ID Number E. Slate Transporter's ID(Reserved.] � �..�Q F. Transporter's Phone t 9. les(! �m gte yliy�ljle no al l�sJ �/ (�L,r1FG1V;M EPA ID Number G. State Facility's ID zk,tl 't V% o..J H:iF llj 33.'1 S01S E,D� 1 � kyl;we Q H. Facility's Phone "-4� Y� M�� C;{-r CA 53a39 c ro o 6 N t boa - Aaa - a54.y 1 CQ� 11. US DOT Description(including Proper Shi oping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit VZ a. No. Type Quantity Wt/Vol I. Waste Number NOwit 3 T r a Stare f $' � N c 2n- 2NnZn• MJ�o5 1� , / Q I 3 G EPA/Other E S m O O 0 N o Ai¢. N t p 4 CID E b /VON - YQ C I1 } 2 ti�J ••3 4!.t 5 T'< 5 a ! Stale 1 0 f v R t� n S.5 Q t.4v1 S O ©O O p EPA/Other N o Ne C14 A o TC. p NON - /2 C/ZA /1 t 0?-0.6.a.f [/�Ab T c So 1:& State O eco O D 1 R C l p e G+ ' vt� QVA I() 3 5 0 f EPA/Other NoNe w d. State Z w U EPA/Other LU ZJ. Additional Descriptions for Materials Listed bove K. Handling Codes for Wastes listed Above o [[4: E 836iY � a. b. LU 116. Eb36Ly ? I r1� . F$31. C. d. l ZI C - t O 15. Special Handling Instructions and Additioni il Information Z Pr•�•� 9,4 kr T .. e-��,. cy ff 8r �j 3 o o 16. GENERATOR'S CERTIFICATION: I hereby c eclare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, Vmarked,and labeled,and are in all respec s in proper condition for transport by highway according to applicable international and national government regulations. t 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 practicable and that I have selected the�r ctica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health rn and the environment;OR,if I am a small cuontity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is Q available to me and that I can afford. yed/Typed Na a Signatur Month Doy Year 1 =" C) 1'�,- w T 17. Transporter 1 Acknowled ement of Recei t f Materials 'j U' R A Printed Typed Name Si n lure _ fylont�i ay Ye10 10 ar j tk,�� LLJ P w 0 18. Trans orter 2 Acknowled ement of Retei t f Materials T Printed/Typed Name natur Month Day Year t LU E V) R U19. Discrepancy Indication Space Z F - A C I L 120.. c ility Owner or Operator Certification of r cei t of hazardous materials covered by this manifest except as noted in Item 19. I Printed/TypeddName Signature � Month Day Year Y C,Tf f f t 1 2 I - 1 DO NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DISC 0 (1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)