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Form Apr-;ovedtOMB No.2050-0039 <br /> i i uic(Expires <br /> ,.9.30- <br /> oiwc of� ..�tuuuu-Li—I-'Ii <br /> 50-0039(Expires 9.30-99) See I(15irUCtIOf15 Ofl BOCK Of Nt"'l: U. Department of toxic Suusiances l.ontru, <br /> Please rnt or e. Form designed for use on elite(12• itch)tyl r. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST 1-10101011 I(Z of <br /> 3. Generator's Name and Mailing Address L 311 A �N A. State Manifest Document Number <br /> 20169573 <br /> i.. i-.,w�a1Hv 2 T..a� . � <br /> q r-rl O3�3 yb--,' B. Slate Generator's ID <br /> O o,Gk lLo A)� /- <br /> hA. Generator's Phone ( q ) <br /> N 5. Transporter 1 Company Name �;T 1.1 Q 6. S EPA ID Number C. State Transporter's ID(Reserve .] <br /> �rf�.0 5���'TO�'rl oVD. Transporter's Phone <br /> b t�a-n o U �-►J c� C 7 0 3 r G 1 C� FGo�-3 Ol <br /> 0 <br /> 7. Transporter 2 Company Name <br /> B. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> i <br /> r�J F. Transporter's Phone <br /> J <br /> VI 2lam --1 p ID Number G. Stale Facility's ID <br /> 1 q <br /> 9. D 19 �f'C'W e d t `Fss tJ l�.!`t:Ll Vim^ UV <br /> d �Pff-� <br /> H. Facility's Phone <br /> J0a3 0 �� �� � —c39lo �{ <br /> .. <br /> 10Z.1 4 11 F7 <br /> 12. Containers 13. Total 14. Unit <br /> D U 11. US DOT Description(including Proper Ship ing Name,Hazard Class,and ID Number) No, Type Quantity WI/Vol I. Waste Number <br /> State <br /> \ -3 ,50 <br /> C EPA/Olher 1 <br /> 3 C' <br /> A-"'IT IJnµ T v +v... r44, r.A/tJ Do -3 >0 0NC <br /> State <br /> EI , <br /> N b. ` pN -n/Q 1� Z/ O .f W/ S?C 5• <br /> d <br /> co <br /> co E EPA/Other <br /> �V /� ` _ ; <br /> v R Sh.ibL.ID�A s T Q 0 0 " <br /> A c state ! <br /> o �� <br /> T (V 0.J -RcA-A 14Z.(✓� I <br /> O EPA/Other' i1 <br /> 00 <br /> a Nage <br /> R � �NT c u-; s l fl N1 na 5 <br /> Slots <br /> � I <br /> U d. <br /> Z EPA/Other,LU <br /> j <br /> U 4 <br /> i J. Additional Descriptions for Materials Listed Alave K. Handling Codes for Wastes Listed Above t <br /> Fd 36&a b• <br /> 't t <br /> 1c5) F636ira. d.ce <br /> 1 <br /> ^, <br /> Q , <br /> Z 15. Special Handling Instructions and Additiona Information 1 <br /> 115- -cel ft...d Cy ::W:0 PIE <br /> 1, <br /> Z <br /> w j y�0— Litt 2ti-�3o0 a <br /> 16. GENERATOR'S CERTIFICATION: I hereby d clare that the contents of this constgnmenl are fully and accurately described above by proper shipping name and are classified,packed, 1, <br /> Q marked,and labeled,and are in all respect in proper condition for transport by highway according to applicable international and national government regulations. 4 <br /> If I om o large quantity generator,I certify hat I have a program.in.ploceAo.reauce the volume and toxicily''oElitTile <br /> generated to the degree I have determined to be economically <br /> procat cable and that I have selected the pro ticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> n and she environment;OR,if I am a small q antity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is 1 <br /> ce available to me and that 1 can afford. l <br /> 0 Month Day Year 'I <br /> y Printed/Typed Name $ignglur <br /> U <br /> w T 17. Transporter 1 Acknowled ement of Recei t o Materials <br /> ce R Mon Day Day Year <br /> rY A Printed/ typed Name Signature 1031 �1 <br /> w e9i CIO I �— <br /> LU <br /> 5 ! <br /> P <br /> B 18. Transporter 2 Ackn wled ement of Recei I o Materials <br /> Month Day Year, <br /> 0 R Printed/Typed Name $ig aWre <br /> Wis E <br /> Q R <br /> U '. 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I � <br /> L <br /> 20. Facility Owner or operator Certification of r ei I of hazardous materials covered by this manifest except as noted in Item 19. � <br /> Printed/Typed Name Signature Month Day Year i <br /> � v.i 1,•> JAI�. I <br /> DO NOT WRITE BELOW THIS LINE. J <br /> i <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8C22A(1/99) To: P.O. Box 400, Sacramento, CA 95812.0400 <br /> EPA 8763-22 1OZ03 e"2, <br />