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,tate of California—Environmental Protection Agency <br /> form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of a 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite( 2-pitch, iter. Sacramento,California <br /> UNIFORM HAZARDOUS I• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator's Name and Mailing Addres A. State Manifest Document Number 1 a <br /> O - -- _ - - B. State Generator's ID - <br /> LO <br /> LO 4. Generator's Phone (_1 ) <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> W) <br /> as <br /> O _ •, - _ D. Transporter's Phone <br /> O <br /> 1. <br /> N 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> ,;y J F. Transporter's Phone <br /> .r V <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> - - - H. Facility's Phone <br /> _ .. .. <br /> J <br /> 12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper hipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/vol I. Waste Number <br /> State <br /> G EPA/Other <br /> .. E <br /> o N b :?�&ZP :�1, ,W to <br /> ... - S to <br /> 00 E <br /> R EPA/Other <br /> CN <br /> r `.d�h.'.. :t '�. ��rn '....; `. _. State. <br /> o T <br /> m O ,, : _ r <br /> R EPA/Other <br /> _ '•J , <br /> ad <br /> LU d State <br /> Z <br /> Uj <br /> V EPA/Other <br /> w <br /> Z J. Additional Descriptions for Materials Lis ed Above K. Handling Codes for Wastes Listed Above <br /> O a b. <br /> LU <br /> C. d. <br /> J <br /> Q <br /> 0 15. Special Handling Instructions and Add tional Information <br /> LU2 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> V <br /> 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 <br /> CL practicable and that I have selected t practicable method of treatment,storage,or disposal currently bvailable to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a s all quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> cd available to me and that I can afford. <br /> O <br /> VPrinted/Typed Name - Signature Month Day Year <br /> Z f . <br /> w T 17. Transporter 1 Acknowledgement of Re ei t of Materials <br /> R <br /> LU 8 Printed/Typed Nome �drya Signature i Month Day, Year <br /> 5 <br /> U_ B 18. Transporter 2 Acknowledgement of Ra ei t of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> LU E <br /> Q <br /> R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> L <br /> 1 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 0 (1/99) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br />