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Stale of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99 "See Instructions On back Of 6. Department of Toxic Substances Control Ij <br /> Please print or type. Form designed for use on elite(12 pitch)h ter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Pae 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS g is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Address ` t} A. State Manifest Document Number <br /> 20169573 <br /> r^ l 7t) B. Slate Generator's ID <br /> A. Generator's Phone (� ) r <br /> 5. Transporter 1 Company Name P�i s V 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> (IAsJ'-+` iy0 Q7A,'�-t o4,) r► l Gf �J/ D. Transporter's Phone _, <br /> 00 <br /> 7. Transporter 2 Company Name 8. Us EPA ID Number E. State Transporter's ID Reserved.] <br /> F. Transporter's Phone <br /> �Q <br /> V 9. Dep• ted Fpcill' Name nd 1if A1ddres E 10. US*A ID Number G. State Facility's ID <br />..y7Z <br /> a.. t • �1n ,.,� � n � , <br /> Z V f 3.1 a m s 1.•v, -tt'iC H. Facility's Phone <br /> Q 12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper Ship ing Name,Hazard Class,and ID Number( No. Type Quantify Wt/Vol I. Waste Number <br /> -jZ a. QState {J <br /> 3 EPA/Other <br /> G I <br /> E C.. .JA.Ail 1)L. ; ;� iy�. eft, r� 3 c ; <br /> N b• State t <br /> 0000 E /V o N G-/111 ?its. v Mc.� ,S', let <br /> v REPA/Other <br /> A C Sf,.,�'I F U 0 <br /> Q. <br /> o T <br /> C. [ state <br /> o rJ U n1 A 11 rt l <br /> REPA/Other <br /> N fl r (J `� <br /> LU d. <br /> � State <br /> Z <br /> U I EPA/Other <br /> u, I <br /> J. Additional Descriptions for Materials Listed Alove `pt K. Handling Codes for Wastes Listed Above <br /> b. <br /> Z If r-.) r b3L�_7 d. <br /> I <br /> O 15. Special Handling Instructions and Additional Information ice: <br /> � C' <br /> Q ',A.) C.A`�` f 1 C f 1 c —• 7 R C G i `f H f: a., .�C y i <br /> Z <br /> Sr a>0 'y:i y- '730 0 f <br /> 16. GENERATOR's CERTIFICATION: I hereby de lore that the contents of this consi n I nt are fully and accurately described above by proper shipping name and ore classified,packed, i <br /> Vmarked,and labeled,and are in all respects in proper condition for transport ghwoy according to applicable international and national government regulations. <br /> If I am a large quantity generator,I certify of 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically a <br /> practicable and that I have selected the prat icable method of treatment,storag�,'`or disposal currently available to me which minimizes the present and future threat to human health { <br /> nand the environment;OR,if I am a small qu 3ntity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is { <br /> ck� available to me and that I can afford. a <br /> OPrinted/Typed Name Month Day Year I <br /> z �t� 2 r —LA -rJ <br /> ua T 17. Trans orter 1 Acknowledgement of Receipt ol Materials <br /> R <br /> LU N Printed/Typed Name ,�-- Signaturid Month Day Year <br /> S - r, ,._— <br /> O0 18. Trans orter 2 Ackn wled ement of Receipt of Materials <br /> T Printed/Typed Name Signature ` Month Day Year <br /> LU <br /> N E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of re -ipt of hazardous materials covered by this manifest except as noted in Item 19. 1. <br /> Printed/Typed Name Signature Month Day Year I <br /> DO NOT WRITE BELOW THIS LINE. ` <br /> DISC 8022A(1/99) <br /> EPA 67700-0-22 Yellow: GENERATOR RETAINS <br /> ,1 <br />