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<br /> Form Approved_OMB No.2050-0039(Expires 9-3 -99) S@@ Instructions Ofl back/ @ 6
<br /> Please print or type- form designed for use on elit (12-pitc vriter. 9 _ r Department of Toxic Substances Control
<br /> i, „r,� Sacramento,California
<br /> UNIFORM HAZARDOU 1• Generator's US EPA ID No. Manifest Document No. 2. Pa:F1
<br /> Information in the shaded areas
<br /> WASTE MANIFEST is not required by Federal law.
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<br /> 3 Generators Name and Mailing Addr ss A. State Manifest Document Number
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<br /> hB. State Generator's ID
<br /> 4, Generator's Phone ( )
<br /> to 5: Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved..]
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<br /> 0 p„}' _ D. Transporter's Phone
<br /> 7. Tr sporter 2 Company Name 8. US EPA ID Number
<br /> - E. State Transporter's ID[Reserved.]
<br /> F. Transporter's Phone },
<br /> 9. Designated Facility Name and:SiteAd rens 10. US EPA ID Number G. State Facility's IDy�iH. Facility's Phone
<br /> Q 11. US DOT Description mcl in Pro Proper hipping Name,Hazard Class,and ID Number) 12. Containers 13. Total_ 14 Unit _
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<br /> y 7 a. No. Type Quantity Wt/vol I. Waste Number
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<br /> _ State
<br /> WON-RCIRAi�, .-�R:oI �W.,Y'E 'Lxc! in
<br /> 3 E y EPA/Other
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<br /> R04 EPA/Other
<br /> State
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<br /> aEPA/Other
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<br /> to J. Additional Descriptions for M terials Ltste Above K. Handling Codes for Wastes Listed Above
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<br /> Z -15. Special Handling Instructions and Additio al Information
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<br /> Q16. GENERATOR'S CERTIFICATIOt1herat declare that the contents of this consignment are fully and accurately described above by proparshipping name andare dassified,packed,
<br /> V marked,and labeled,and areis in proper condition for transport by highway according to applicable international and national government regulations.
<br /> If l am a large quantigenerthat I havea progQram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicallh practicable.and that I have selacticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healti and the environment;OR, if I l udntity ggnerafor,I have made a good faitheffort to minimize my waste generation and select the best waste management method that is
<br /> 0available to me and that I can
<br /> VPrinted/Typed Name Signature , 7 Month Day Year
<br /> R17 Trans orter 1 Acknowledgement of Receipj of Materials
<br /> w B Printed/Typed acme y. Si nature s
<br /> Month Day,.,. Year
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<br /> uL 0 18. Transporter 2 Acknowled emint of Recei t of Materials
<br /> 0 T Printed/Typed Name Si nature•v,
<br /> LU E 1 9i Month Day Year
<br /> V F 19. Discrepancy Indication.Space
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<br /> 1 20. Facility Owner or Operator Certification of etei t of hazardous materials covered by this manifest except as noted.iriltem 19.
<br /> T Printed/Typed Name,' "• Signature ,. .,✓' ,
<br /> Y _ .. Month Day Year
<br /> L ERVICES DO NOT WRITE BELOW THIS LINE.
<br /> APR 8 " 200Z Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.
<br /> DTSC,8022A (1/99) (Generators who submit hazardous waste for transport out-of-state;
<br /> EFA 8700-22 produce completed copy,of this copy,and send.to DTSC within 30 days.)
<br /> BEVERLY ROSS
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