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State of California—Environmental Protection Agency <br />'Form Ap roved OMB No 2050-0039(Expires 9 3D 99) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please int or type form desrgnedfor use on elle f12 pitch)typewriter P Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Information ro the shaded areas <br /> is not required by Federal iow <br /> WASTE-MANIFEST 1 r i 1 4- � <br /> 3 Generator a Name and Mailing Address T -4" —7 Lr y-s 1 A Slate Manifest Document Number + <br /> l ft tL7 1 11506, <br /> 02 <br /> n �� B'State Generator s 10 <br /> 4 Generators Phone (� i+f�', fy �� <br /> 5 Transporter I Company Name 6 US EPA ID Numberr <br /> C StaleTrnnsparter's ID[Reserved] _ <br /> VALI.., Y"� A� ;TE OIL C: A L 1B Q 0 71 A 4�4 ❑ Transporlers Phone x'7114-4"4b <br /> 7 Transporter 2 Company Name B US EPA ID Number E State Transporters iD[Reserved I f l <br /> J <br /> J <br /> Q F-7ransporter's Phone " w <br /> 10 US EPA ID Number G 'St to WhI s It, <br /> t" �L Ates €"+.OAA <br /> L� liO PIVE BAN ,CA 91,5367` 1 { 1 H Fasa�� -4613-81 I 199M- 9 11 - <br /> 11 US DOT Descripteon f mcludmg Proper Shipping Name Hazard Class and ID Number) I2 Containers 1 3 Total 14 Unit <br /> NOf,�fy�+i�,J� J! ��ag d¢'�,q7T�� +tq; t.p�s T #p1E g'R No Type Quantity Wt/Vol I Waste Number- <br /> N NO RE4ni�A��JIlP�RDO`.�S VA,5 i C��i*++4"i,�IV Stat9 21 ' <br /> t= Q11. _ 4 <br /> � � �A��� � i � � � � �r EPA/Other <br /> f <br /> N b s State <br /> 03 E <br /> IR "EPA/Other _ <br /> A <br /> T State <br /> co O " <br /> R EPA/Other ; <br /> d <br /> state,-- <br /> U <br /> tate 4U EPA/011ier <br /> .- <br /> -J-Additional�De,rscriphons for Matenafs Listed Above _ _ K Handimi;Cffbdes for Wastes fisted AboveLU <br /> Y' <br /> iY <br /> d M J <br /> Y15 Special Hondling Instructions andAdditionalInformation r I <br /> C' r-R0 I CY, P140NE 209 667-88 3 5-M K-U1\1 CO <br /> 16 GENERATOR 5 CERTIFICATION 1 hereby declore that the contents of this consignment ore fully and accurately described above by proper shipping name and are classified packed <br /> Q marked and labeled and are in all respects m proper condition For transport by highway according to applicable international and nohonal government regulations <br /> If I am a large quantily generator I certify that I have a program in place to reduce the volume and toxic%of waste generated Yo the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment storage or disposa{currently available to me which minimizes the present and futuie threat to human health <br /> and the environment OR, if 1 am a small quantity generator I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford <br /> [Tninto,7d/�T�p.d Name, Signature t Month Day r;Year <br /> r t <br /> ,r.,rw y ,�r i _ !� .. 'ter„ rd+r <br /> B17 Transporter 1 Acknowied emerit of Receipt of Materials <br /> A Prrnted/Typed Name 5, nature <br /> B � � } Month Day# Year <br /> 8 18 Transporter 2 Acknowled ement of Receipt of Materials <br /> T Printed/Typed NameSignature Month Day Year <br /> LU E <br /> R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> L <br /> 1 20 Focdi Owner or O orator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> r <br /> 11 Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> WTSC 022A {1/991 <br /> A 87700-22 Yellow GENERATOR RETAINS <br />