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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30.991 See Instructions on back of page 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch)typewriter. Sacramento,California <br /> UNIFORM HAZARDOUS 1., Generator's UUgS EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is ,/ 1 1} `� "I C: "2 � / of is not required by Federal law. <br /> 3. Generator's Name and Mailing Address 1t 10�0 C 0 A. State Manifest Document Number , <br /> -y Ijq <br /> -IN 32_1 <br /> I B. State Generator's ID <br /> LO 4. Generator's PhoneA(Y-1 [ �� � y ti ." l� ) t' iy 1�j <br /> N <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> ,rI <br /> D. Transporter's PhoneO 1p^fi]( fY VAI-LEY FAw' y 0!L. IC. A I-11110 82RO f C <br /> .. <br /> O <br /> ao 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> i Q F. Transporter's Phone <br /> U Q.;4gjigsa end r4ayy ttyN a 9n�laS�'�{r �fc e�ss 10. US EPA ID Number G. State.Fau,lity's ID <br /> Q ., ,.. S .a3;S,• t,l �i,�,_.. ,..i4° ,, <br /> � f" p �t A{r,�.' �4 rr�� LL�� �5 1-11,11,110 <br /> r r1 ��yy /� q yy �� a H. Facility's Phone <br /> a1) 0 t-'lVf..} €:/CNK. CA 9536 � A 1- !,I ,1 0 ! 9 1018 <br /> C7 f �,3 :-•I.P��+.7••��,ISA S <br /> LL <br /> Q 12. Containers 13. Total 14. Unit <br /> U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> a. NON i�NG tip,#~ilSi�'.E`+,i'tDOU i �tt°�:kT%'- t..if,�IJIO stare <br /> 3OILY rtKY>wt y f 1 t. I Y <br /> f�CJ EPA/Other <br /> o N b. State <br /> oaDo E <br /> R EPA/Other <br /> qA C. State <br /> o T <br /> w O <br /> R EPA/Other <br /> LU d. State <br /> H <br /> Z <br /> w <br /> U EPA/Other <br /> LU <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> .Jf f `:°?AV.i. <br /> ui <br /> cy C. d. <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> ZL':.IM�i140-ENC Y PHONE?.09-867-8415? <br /> LU <br /> 2 <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 /> U marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and not, <br /> government regulations. <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 /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N and the environment;OR,if I 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 /> W available to me and that I can afford. <br /> 0 <br /> r Printed/Typed Name Signature Month Day Year <br /> ♦t ( / <. <br /> w T 17. Trans porter 1 Acknowledgement of Receipt of Materials <br /> � p yp d Nome Signature s Month Day Year <br /> w Printed/T e j <br /> w S <br /> P <br /> LL0 18. Transporter 2 Acknowledgement of Receipt of MSterials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E <br /> V) R <br /> U19. Discrepancy Indication Space <br /> F <br /> Z <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner 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 /> DTSC 80 (1/99) <br /> EPA 8700-0-22 Yellow: GENERATOR RETAINS <br />