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State of Calitorn la—Environmental Protection Agency M 1 Form Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control Please print or type Form designed For use on ebte(12 prtch)typewriter Sacramento California UNIFORM HAZARDOUS ! Generator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas WASTE MANIFESTr ] Lj �+ � � � � � of � is not required by Federal low 3 Generator s Nome and Ma31mg Address on o- d r' 7) A State Manifest Dacumeni Number 1 6 8 6 ' Xi+ L.i l i`, 8 SFate Generator s ID 1 n4 Generator s Phone� ] q i � Ca `1, 1 Yl N 5 Transporter 1 Company Name 6 US EPA ID Number i ! C State Transporter's ID[Reserved] LO M fel l�(r!f'w 'VALLEY V'eArr N �' 0IL Sit t_ 0 0 Q a 2 1 A. !' 13 D Transporters Phone U.4Av O ca 7 Transporter 2 Company Name 8 US EPA ID Number E State Fransporter's{D[Reserved] a Q P Transporter c Phone V �,r r� c Edi i{y N`a �arf i dd e3s� 10 US EPA ID Number G Stet,Fag,ly s lD $3 Z300 OI,. tJS ROAD 0 RINPF. .9AK,, CA 95367 i .. � � � � � 0 � 1 61H J U11 US DOT Description(including Proper Shipping Name,Hazard Class and ID Number) 12 Containers 13 Total 14 Umt Z o No Type Quantity' Wt/vof I Waste Number I' = ON-�RCHA F4,AJARDOUS WAST 1 LIfi UiD State, 221 3 G ( OILYIq TSR 0 O 1 T T E EPA/Other io N b State a0o E R EPA/Other 10 o T T o Sia to 5, co O R EPA/Other d x FLU d State w V EPA/Other I ;i,s , U4 ax J Additional Descriptions � r . Descri tions for Materials Listed i AboveHandling. s�s a�o',v5t.-s.i ti�p't+1r #,�ilt'ra v,1y.t,St t i•` 3 ni r.,`�+c,`.a.,,Ai°•y.ls,��,Z _to�r. �r aKs HanR/!d fr e'ni.g..Cord�e�s for �rW a<istes SLis`Mt,er}d Above ' Y brypZ K f1 ,4 lL ls_ c d , I q e� 6 � � . ' �, ` i� t 1 > r`.k' •- ' a p> ' e; ,>'F � �i `t a,}� ° i 9 � 10Z 15 Special Handling Instructions and Additional Information a 31 OVES Lu EMr-RCIENCY PHONE- 209-667 8857 Z J 16 GfNERATOR'S CERTIFICATION I hereby declare that the cantenfs of this consignment are fully and accurately described above by proper shipping name and are classified packed Umarked and labeled and are in all respects in proper condition for transport by highway according to app icoble international and national government regulaiions —i 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 practicable and that f have selected the procticoble method of ireatment storoge or disposal currently available to me which minimizes the present and future threat to human health and the environment OR, if I am a small quantity generator I have mode a good forth effort to minimize my waste generation and select the best waste management method that is o-1,61e to me and that I con afford O} Printed/Typed Nome y J 3 /rf Signature 7 ,.� �t �+, �r� Month Day Year 'tz f 1 1� j7 S/f- ']�r 1 e•{ 7`©I 03, T 17 Transporter 1 Acknowledgement of Receipt of Materials R 7 LU H Printed/Typed Nome r� Signature s Month (pay Year 1 w T r �'a R�r' Er �f..P"! 41�� 3 C]ac.i? { -,S� ! r_ p 18 Transporter 2 Acknowledgement of Receipt of Materials 0 R Printed/Typed Name nature Si E 8 Month Day Year LO R a V 19 Discrepancy Indication Space Z f A C 1 ' L f 20 Foals Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in item 19 Printed/Typed Name r Signaturer --Tom onth Day Year ;r4f f � DO NOT WRITE BELOW T IJSJINE Yellow TSDf SENDS THIS COPY TO GENERATOR WITH[N 30 DAYS ' DTSC 8022A (1/99[ IGencrators who ..ubm,t hazardous waste for transport out of state EPA 8700-22 produce romploled copy of thrs copy and send to DTSC wilhin 30 days}