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Form Approved OMB No.2050-0039(Expires 9-30-9 I Jtlli Ilt3II ULilvill uu uu— ur rut,,, V. Ueparnnenl of loxic Substances lontroi <br /> Please print or type! Form designed for use on elite(12-pitch) •rifer. Sacramento,California <br /> UNIFORM HAZARDOUS nerator's US EPA ID No. Manifest Document t 2. Page 1 Information in the shaded areas <br /> is not required by•Federol law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address A A. Slate Manifest Document Number <br /> kcy�T„N. A.-+-we4;.,e ti ,"c <br /> 3e2 S. 5*1 D.0P.4J r7 S T . -� <br /> 2016 <br /> O ^ c1 -A p 76_3 Ya B. State Generator's ID <br /> e M f-f I J <br /> 4. Generator's Phone ( 5 I v G [ ,� ks <br /> `N 5. Transporter 1 Company Name pL;` Q 6. U5 EPA ID Number C. State Transporter's ID[Reserved.] <br /> ^C QA.�5 PO f�'T A-n o1) T C D. Transporter's Phone <br /> m 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> �• / F. Transporter's Phone <br /> a �,{ <br /> U 9. D�e�,I�Lefiey,' c fe r 4 s` �A[�I A�;j�FA ID Number G. State Facility's ID <br /> 4A AJT <br /> ^O S I G 5' Jy I.wrc +\[ H. Facility's Phone � '�Q <br /> .�u.. w r G7 n � 1 <br /> 12. Containers 13. Total 14. Unit <br /> v�U11. US DOT Description(including Proper 5 ipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> `V Z a p � t State <br /> = <br /> NOH .�)z.Md•.+, w �t5"e 301:Q ?. <br /> G0A+rU7 5 1 " J O D1,3151 <br /> EPA Other <br /> '7 J I`� • �'lw <br /> E A /I State <br /> o E b A ON -/`I2G.4R + X17*—nJ.Fw c ,A'S c $. 0A <br /> N R (. S."'k w A s T JR, 5 CA le Q t/ t' EPA/Other O 4 <br /> -T A Stale <br /> o T ` NU <br /> 4C AA ) f2,-1Q- ..f' L-�STr <br /> co O EP /Other <br /> R r -� cut SQ b IM 010131510 <br /> Lu d. stare <br /> L- <br /> w EPA/Other <br /> U <br /> w <br /> Lo J. Additional Descriptions for Materials Lisle Above K. Handling Codes for Wastes Listed Above <br /> o ���� r8 a6ba b. <br /> wcX: 1 ,5� F636tY <br /> Q <br /> If �) F 631"7 <br /> Z 15. Special Handling Instructions and Addili nal Information <br /> O <br /> Q W cA �►o �� A 1'� CIJe -- 7A t <br /> Z <br /> _ <br /> t— <br /> 16. GENERATOR'S CERTIFICATION: I here y declare that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all res ects in proper condition for transport by highway according to applicable international and notional government regulations. <br /> If I am a large quantity generator,I ce ify that I have a program in place to reduce the volume and foxicify of waste generated to the degree I have determined to be economically <br /> v7 <br /> practicable and that I have selected the raccicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> 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 <br /> available to me and that I can afford. <br /> 0 <br /> � Printed/Typed Name ` Sign ur �1 Month Day Year <br /> Z Q <br /> w T 17. Transporter I Acknowledgement of Rece pt of Materials <br /> R 1 Month Da Year <br /> Lu <br /> p Printed/yped Name ..-Ament <br /> Signature G y <br /> Lu <br /> w B 18. Transporter 2 Ackn wled fRecel of Materials <br /> R Printed/Typed Name Sig ature ( Month Day Year <br /> w E <br /> N R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20. Facilit Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Month D <br /> T Printed/Typed Name Signature ay Year <br /> DO NOT WRITE BEL W THIS LINE. ,y <br /> Yollow. TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 8022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.) <br /> EPA 8700-22 <br />