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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30- ) See Instructions on back o' 3e 6. Department of Toxic Substances Control <br /> Pleaseprint or type. Form designed for use on elite It 2-pitch. niter. - Sacramento,California <br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal law. <br /> 3. Generators Name and Mailing Address ; A. State Manifest Document Number <br /> B. State Generator's ID <br /> 4: Ger efator'i~Phone r ] <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> 00 <br /> D. Transporter's Phone <br /> '"jop . Transporter 2 Company Name <br /> 7 Y r, P P 8. US EPA ID Number E. State Transporter's ID[Reserved] <br /> J <br /> F. Transporter's Phone <br /> T 9. Designated Facility Name and Site Addr ss 10. US EPA ID Number G. State Facility's ID <br /> T <br /> H. Facility's Phone <br /> J <br /> ?14 Q 12. Containers 13. Total 14. Unit <br /> a]U 11. US DOT Description(including Proper Sh pping Name,Hazard Class,and ID Number( No. Type Quantity Wt/Vol I. Waste Number <br /> = a. i,;: tia k a 1... ..Z t L . .,,_., _ . State <br /> 3 GEPA/Other <br /> c, N b. T,"`., ..,...�.... "•.^`�+ -�': _ xa�_>:j a3,�'N. 1j°t,..is, State ..I . <br /> o0o E EPA/Other ' <br /> v A t <br /> O T c iga 7r c. .�..A,.-.15 r. ingga&l,ic r T': ...._ ° State <br /> m O 1;1`'x; 9�.. :?M ,� ►::4 a�,zt � i <br /> R rJ `f EPA/Other <br /> a <br /> LU d. ':q:;F'4•"1^ +5+1`R.:" .;t.7-. !.5,'ti:.^S' X. 5xt4�:li7.�,'L*r "C:::"u.�,.+"$'d'. t::r State <br /> Lu <br /> .. y <br /> EPA/Other <br /> LU <br /> Z J. Additional Descriptions for Materials Listed Bove K. Handling Codes for Wastes Listed Above <br /> a <br /> a. b. <br /> LU <br /> C. d. <br /> J <br /> Q15. Special Handling Instructions and Additio al Information <br /> Q <br /> Z _i+1Lwi *ri^" e�K.24n'' "�ca. ':s <br /> W <br /> Q 16. GENERATOR'S CERTIFICATION: I1 <br /> eclare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> U marked,and labeled,and are in all resp. is in proper condition for transport by highway according to applicable international and national government regulations. <br /> J n• <br /> If I am a large quantity generator,I certi 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 /> hpracticable and that I have selected the�r cticable 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 small uantity generator,1 have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> ce available to me and that I can afford. =? r s <br /> . i,:r 2,n •r1. }r i.Zl.'iJ ....qpw <br /> r Printed/Typed Name Signature' Month Day Year <br /> LU <br /> Z <br /> R 17. Transporter 1 Acknowled err ent of Receipt of Materials <br /> LU <br /> N Printed�Typed Name Signature r` i ,r Month;i' Day Year <br /> LU F r �;a .•. c 9 -u'.::�^^�na.. r, �� �.v,. .yL.: <br /> O0 18. Transporter 2 Acknowledgement of Receipt f Materials = <br /> T Printed/Typed Name Signature Month Day Year <br /> w E <br /> N R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I. <br /> L <br /> I 20. Facility Owner or Operator Certification of ecei t of hazardous materials covered 6y this manifest except as noted in Item 19. <br /> 7 Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 0 (1/99) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br />