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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back Of 6. Department of Toxic Substances Control <br />e. <br />`Pleo-se'prinlrlpForm designed for use on elite (12-pitch&lter. Sacramento, California <br />W <br />LU <br />t— <br />Z <br />V <br />LLJ <br />GO <br />Z <br />0 <br />a_ <br />V) <br />LU <br />Z <br />0 <br />Z <br />W <br />I I L <br />'krI" <br />UNIFORM HAZARDOUS <br />'M <br />. enerator's US EPA ID No. Manifest Document No. <br />2. Page I <br />Information in the shaded areas <br />WASTE MANIFEST <br />1 <br />- -- — <br />X7 P, _- " 1 19 1 — � <br />�� "1 P> <br />_4 V d" 1­:� <br />; <br />of <br />is not required by Federal law. <br />-4 <br />3. GeneratorNa P PO4-4ai I Address <br />N F) 05. <br />A. State Manifest Document Number <br />2 21.2 7 5 <br />B. State Generator's ID <br />t <br />4. Generator's Phon(k�' <br />1 <br />5. Transporter I Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />1_ARV1ffikTP1�'1.t4?, N r4 <br />D. Transporter's Phone (510AItl 4V <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserve <br />F. Transporter's Phone <br />arp! and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />t 10121 <br />H. Facility's Phone <br />X_vl <br />(51(1)47&,1740 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />14. Unit <br />No. <br />— <br />Type <br />Quantity <br />Wt/Vol <br />I. Waste Number <br />a, <br />4 P, A HA F 1A <br />State <br />G <br />EPA/ t,& <br />N <br />6. <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />C. <br />State <br />0 <br />EPA/Other <br />R <br />d. <br />tate <br />State <br />=EPA/Other <br />J. Additional Descriptions for Materials Listed Above, <br />K. Handling Codes -for Wastes <br />Listed Above <br />a. <br />6• <br />c <br />d . <br />ljktSriq� dlig Instructions and Additional Information <br />V4VIN' ViRlr' HAYWPkIR P '5 VA -476, V /'4- 14'14 <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 />labeled, for <br />marked, and and are in all respects in proper condition transport by highway according to applicable international and national government regulations. <br />If I am I <br />a largedctu,,,�� I generatori'l certify that I have a proyrom-in place to*reduce the volume and toxicity of waste generated to. the degree I have determined to be economically <br />that disposal <br />practicable an ave selected the practicable method a treatment, or currently available to me which minimizes the present and future threat to human health <br />I <br />and the environment; OR, if I am a small quantity generator, I have ma 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 />Printed/Typed Name <br />Signature <br />Month',` Day, yqq5 <br />T <br />17. Transporter I Acknowledgement of.Receipt of Materials <br />R <br />A <br />Printed/Typed NaAfe <br />Signature . <br />Month,Day Year, <br />S <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />20 F acit *I' I Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) <br />EPA 8700-22 Yellow: GENERATOR RETAINS <br />