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State of California—Enrironmemal Protection Agency <br /> Form Approved OMB No 2030-0039(Expires 9 30-94) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type form desrgned for usa on efrte(72prtch)typewrrMr Sacramento California <br /> UNIFORM HAZARDOUS 1 Generators US EPA ID No Manifest Document No 2 Page I Information in the shaded areas <br /> WASTE MANIFEST 7 is not required by Federal law <br /> of <br /> 3 Generato s Name and Marling Addross /l u° at yin' r <br /> 4 Generator s Phone P 0 6-LGT" 9 7 } s <br /> 00 <br /> 9 S Transporter 1 Company Name 6 US EPA ID Number <br /> 00 <br /> PRC ICAT080 10 1111105 19 <br /> Q7 Transporter 2 Company Name 8 US EPA ID Number <br /> U <br /> rtQ w� s` 5 <br /> f� <br /> Q 9 Designated Faolrty Name and Site Address 10 US EPA ID Number <br /> W PRC PATTERSOh, INC. <br /> u_ 13331 N. HWY. 33 ® <br /> Q PATTER5Ot3, CA 95363 C A D U 8 3 1 6 6 7 2 8 � .: <br />' U 12 Containers 13 Toral 14 Unit <br /> y 11 US DOT Descnptton(including Proper Shipping Name Hazard Class and ID Number) <br /> f Z No T Quantiy Wt/Vol I.W43 <br /> a State` <br /> E NON RCRA HAZARDOUS WASTE LIQUID 01011 T T V G I, , <br /> O N b St <br /> ao E <br /> N R EPA Cttlte Ha <br /> v A <br /> o T c AAff <br /> 0 <br /> R <br /> r <br /> W <br /> f' d <br /> Z <br /> W <br /> V <br /> _ l <br /> 1 add, #ar rtals� "%) )C"Aandh es for wastes Usted Above`s <br /> e <br /> LU <br /> 15 Special Handling Instructions and Additional Information <br /> a 24 11R. EMERGENCY CONTACT: PRC #1--(804)-874-4444 <br /> Z 24 HR. EMERGENCY RESPONSE: CHEM TEL INC. #1—(800)--255--3924 <br /> = APPROPRIATE PROTECTIVE CLOTHING & RESPIRATOR. 1 <br /> r- <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 <br /> packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and natronol government regulations <br /> U <br /> J H I am a large quantity generator I certify that I have a program in place to reduce the volume and taxrcty of waste generated to the degree I have determined to be <br /> economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future <br /> threat to human health and the environment OR if I am a small quantity generator I have made a good forth effort to minimize my waste generation and select the best l <br /> waste management method that is available to me and that I can afford { <br /> Prrntbd/Typed Name / Signature Mont "J� Year <br /> - 5 <br /> j `ail G r� r� ' t - - — - / ell `f - / y a <br /> U T 17 Transporter 1 Acknowled ement of Receipt of Materials <br /> w A Printed/Ted Srgnatur Mo a <br /> ce P 1 - C' �.JM <br /> 0 18 Trans orter 2 Acknowled einem of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year j <br /> U_ E �I <br /> O 0. 7 <br /> to 19 Discrepancy Indication Space <br /> IF <br /> U C t <br /> Z I � I <br /> L <br /> 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Year { <br /> 1 <br /> l <br /> DO NOT WRITE BELOW THIS LINE <br /> E <br /> f <br /> DTSC 8022A (9/93) Yellow GENCRATOR RETAINS <br /> EPA 8700-22 lJ <br />