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Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions On back of page 6. Department of Toxic Substances Control <br /> Please print or' pe. Form designed for use on elite(12-pitch)typewriter. y Sacramento,California <br /> UNIFORM HAZARDOUS aerator's US EPA ID No Manifest Documentip 2. Page 1 1 Information.in the shaded areas <br /> is not required by Federal low. <br /> WASTE MANIFEST W Old 01211114 0- I I0, <br /> 3. Generator's Name and Mailing Address A State Manifest Document Number <br /> rwe4P:nrp WGSr Me,•:n.e SCPVa=mss ry' � .. t 21898461 <br /> S t®GL' 1-"- IJP GA -1 J vLi9 B. State Generators ID <br /> LA. Generator's Phone(.� <br /> 'sN 5. Trans orter 1�C�omp/a�n/y/N�a�Jm�e 6. US EPA ID Number C. State Transporter's ID Reserved.] - <br /> 0 // D. Transporter's Phone <br /> C? 7. Transporter 2 Company Nome 8. US EPA ID Number E. State Transporter's ID[ eserve .) <br /> JF. Transporters Phone <br /> V 9.P � i' am dd 10. US EPA ID Number G. State aubry's ID <br /> Z 3S" '�$1 ?j IOC Sky/;�rC /6dC H Facility's Phone <br /> O c L.` -U-13F5 i I I r7 4J-0 0' 3- S-SI 1. <br /> 12. Containers 13. Total 14. Unit <br /> ")V 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) No. Type Quantity Wt/Vol (:'Waste <br /> �2 a tjo!V—Q CAA A Z A---Ld 3 4 6 [A3/V-5'7-C, 5Z State <br /> S <br /> GCSp, G�+T .a cd tvt C� t/ ® (� EPA/Other®N <br /> C,4 E b. State, <br /> 00 <br /> a� E EPA/Other <br /> v R - <br /> A C. State .. <br /> o T <br /> 00 R EPA/Other <br /> LU d. / State <br /> V <br /> FZ / <br /> U-1 EPA/Other <br /> LU <br /> J. Additional Descriptions for M rials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> v, <br /> LU <br /> C. d. <br /> 15. Special Handling Ins ucti ns and Additional information <br /> Q �^re �E c.-5c.,cy r-o .rrkcT N>, r- ! tvt}vws TRcC FjfOQ��3� "93®O <br /> Z <br /> w /> <br /> 16. GENERATOR CERTIFlCATION: • reby declare t e conten this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all re ecL a. roe�r__i i n for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator,I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a- 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 /> 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 /> available to me and that I can afford. <br /> O P nted T ped Name Si Month ay Year <br /> LD17. Transporter 1 Acknowledgement of Receipt of Materials <br /> °-' p Printed/ Name Signature/ Mpnth Qay Y r <br /> w R � <br /> S <br /> P <br /> B 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E <br /> V) R <br /> Q <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> i <br /> t <br /> f 20. Facility Owner or Operator Certification of receipt of hazardous materials co ered b this manifest except as noted in Item 19. <br /> P+t <br /> T Po Typed Name Sign t re Month Day Year <br /> YQlo ia <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) °' �=77-IiS CO,Y TO DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 - ca 30.^,0, Sa_.ame„to, CA 95812 <br />