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f iforma= Environmental Protegtion Agency <br />r p�p�rgveddM6 No. 2050 9 (Gpires 9-30-99) ;.S { <br />o3�p it or type.' ,f o signed for use on elite f 12-0c�vriter. <br />r 40 <br />O <br />f\ <br />N <br />LO <br />00 <br />R • <br />ad <br />LL <br />f- <br />Z <br />LL <br />L <br />LL <br />v; <br />Z <br />C <br />N <br />LLa <br />Z <br />C <br />P <br />Q <br />Z <br />LL <br />2 <br />H <br />Q <br />U <br />CL <br />U <br />at <br />C <br />z <br />See Instructions on back q&e 6. Department of Toxic Substances Control <br />Sacramento, California <br />DO NOT WRITE BELOW THIS LIN-'--' <br />Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br />DTSC 8022A (1/99) (Generators who mit, hazardous waste for transport out-of-state, <br />EPA 6700-22 produce completed co y of this copy and send to DTSC within 30 days.) <br />1. Generator's US EPA ID No. Manifest Document No. <br />2.Ptge 1 <br />Information in the shaded areas <br />UNIEORM HAZARDOUS <br />WASTE MANIFEST <br />• T > 0 ) ft 0 'l 7 l =1 9 'p , <br />aF;. 1 <br />is not required by Federal law. <br />a' <br />t3 �ae418L e ,ft,�g Address f <br />A: StoteMonifest ocumentNumber , <br />2209158%"1 <br />7? �D VOIN 7528 <br />N#WICKI' ON, CA <br />B. State Generator's ID <br />. Generator's Phone (2 0 9 4 4 ~ 5-v %g 1} <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />MOP ?a . <br />r f) ct q `7? t A 0 tl ti_l 0't <br />D. Transporter's Phone 4 V <br />7. Tfawcporter 2 Com ny N e 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />s C} 0 (i t 13 �q 11 / } <br />F. Transporter's Phone f 'Al <br />�gg si i�i Site Address 10. US EPA ID Number <br />G. Sta <br />`', 9 i .. <br />,.. <br />H. Facility's Phone <br />r A. i 'T ft *3 1 1, J 13 ,; 6 f :(. <br />{S2-1) 268 t� <br />11. U$ DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />nt <br />12. Coainers <br />13. Total <br />Quantity <br />14. UnitNo. <br />Wt/Vol <br />1. Waste Number <br />Type <br />.: <br />State141 <br />G <br />EPA/Otbbo <br />E <br />N <br />b. , : � A.3 r KEa � <br />state <br />28 <br />EPAYA h9YE rcr <br />R <br />c <br />LI t$ <br />i imoK <br />A <br />,r°�.� <br />ie <br />State <br />` <br />EPAOther <br />R <br />a„ <br />d. <br />State <br />EPA/Other <br />Adh f r d AbXK ~s <br />TIVIL"rd. <br />K. Handling Codes for Wastes Listed Above <br />yr <br />ns a •d f <br />tt "Lf c 11 . <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 classi ffed, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />IFI 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 economical) <br />that I have the treatment, disposal to the future threat to human health <br />practicable and selected practicable method of storage, or currently available me which minimizes present and <br />and the environment; OR, FF I am a small quantity generator, I have made a good faith effort to minimize my waste generation 6nd select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Ty ed Name t <br />T <br />Signature ✓ f /1i <br />rim, <br />Month Day Year <br />1"� <br />t d Ef <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />R <br />Printed/Typed Name <br />Signature ' <br />Month Day Year <br />0 <br />18. Transporter 2 Ackncwledg2ment of Receipt of Materials <br />T <br />E <br />Printed/Typed Name - .i9 _ <br />9x, ." <br />Signature }.., �., <br />Month Day Year <br />`p <br />R <br />j `� ; . £ <br />1 - AGILITY IN L05 <br />19.... Discrepancy Indica ion pace - ANGELES*, ChBLIORNIA HAS THE ` <br />C <br />TO RECEIVE YOUR <br />APPROE'RWE PERMITS <br />I <br />W&STJ,EAM AS OWIEIEA OUR EA <br />(20. <br />Facility Ownjr o Operator Cer ification of r t of hazardous materials <br />covered b <br />T <br />Printed/Typed a <br />Signature _ nth D Year <br />DO NOT WRITE BELOW THIS LIN-'--' <br />Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS, <br />DTSC 8022A (1/99) (Generators who mit, hazardous waste for transport out-of-state, <br />EPA 6700-22 produce completed co y of this copy and send to DTSC within 30 days.) <br />