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A <br />State of California—Environmental Protection Agency <br />t` Form Approved OMB No. 2050-0039 (Expires 9-30-9,9) See Instrudions On back O ge <br />l( Please print or type. Form designed A*, use, on elite (12 -pits rites <br />J; 1. Generator's US EPA ID No. Manifest Document No. <br />j UNIFORM :HAZARDOUS <br />WASTE MANIFEST C I Al1#1 t) 1 U 1 0 1 04 r 1 9 1 1 1 0 1 0 <br />3. Generator's Mame and Mailing Address <br />CJLLITORN33L CLMAR <br />P.O. S219 <br />B I CA 9201 <br />LA: Generator's Phone ( 209 ) 944-5200 <br />C4 5, Transporter I Company Name 6. US EPA ID Number <br />o <br />smolp Hkimms Sowimms tti A 0 0 0 0 6$ f <br />00Q <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />CP <br />Foci li Name and Site Address 10. US EPA ID Number <br />i <br />�eliiiiilri■iel��®® <br />H <br />HIM <br />Department of Toxic Substances Control <br />Sacramento, California <br />2. Page 1 Information in the shaded areas <br />is not required by Federal law. <br />of <br />13. Total 1 14. Unit' <br />15. Special Handling Instructions and Additional Information <br />APPROP*lh*T Z i 1240 W_ WABHT-NOTON 21T., STOCMN, iA <br />Z <br />NOWMEWY C : (90) 746-7449- <br />U S -A _G. PAOC #126 <br />t- <br />16. GENERMOO'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 />Vmarked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />O1 <br />If I am a' large quantity generator, I certify that I have a pr ram 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 <br />Tom <br />storage, or disposal currently available to me which minimizes the present and future threat to human health <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generatic and select the best waste management method that is <br />available to me and that I can afford. 9 <br />Printed/Typed Name q j ( Signature a� _ Month p Day Year <br />`w S <br />P <br />U_ 0 18. Trons orlerl <br />w0 T Printed/Typed Ni <br />UJ E <br />cry R <br />U 19. Discrepancy <br />Z IF <br />A <br />C <br />1 <br />L <br />1 20. Facility Own <br />T Printed/Typed t ,A <br />v <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />Space <br />of Receict of <br />Signature <br />Signature <br />Signature <br />as <br />Month Day Year <br />Month Day Year <br />Month Day Year <br />Yellow: GENERATOR RETAINS <br />