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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 paae 6. Department of Toxic Substances Control <br />"Please`pt'irkoy4ype. Form designed for use on elite (12 -pitch) Iffiltr. Sacramento, California <br />6 <br />O <br />ao <br />ao <br />N <br />V <br />O <br />O <br />aD <br />ce <br />LU <br />t - <br />Z <br />LUU <br />LU <br />N <br />Z <br />0 <br />0- <br />V) <br />LUa <br />z <br />O <br />Q <br />Z <br />H <br />Q <br />U <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow GENERATOR RETPA!NEl <br />EPA 8700-22 <br />erator's US EPA ID No Manifest Document N <br />2. Page 1 <br />Information in the shaded areas <br />rt)NIFORM HAZARDOUS <br />is not required by Federal law. <br />WASTE MANIFEST <br />'r <br />-.{ � i <br />of <br />" 3p Generators Named Address <br />�'� e4 to ..« <br />i <br />A. State Manifest Document Number .0 per , <br />fu <br />P•"moi ..d° ,IP <br />- <br />��..r �/ <br />`�.�`�a `.e.✓�gew'bwf ..✓ r ..Fr..p.:C ...�r�r.:+.s. .T' <br />B. Slate Generator's 1D <br />.x` w;; <br />A. Generator's Phoned _4- <br />4w=5. <br />5.Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />D. Transporter's Phone <' 'Jf174 11 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. _State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9 Dessqr)at focp�ityName and Site Address 10, US EPA ID Number <br />G State Facility's ID <br />.-fit t i-- t k I` fJ` <br />/��r <br />.-•,.) '�� °�' r <br />H. Facility's Phone <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt Vol <br />I. Waste Number <br />No. <br />Type <br />.r <br />- °� - - a....?k.,r-�°a.,.0 ,�'-��` — <br />.. ... <br />_ - <br />... _ _ <br />- <br />Stat -�, <br />G <br />w ` �t f <br />{ <br />4F A <br />EPA/0r <br />^N <br />6, <br />State <br />E <br />EPA/Other <br />R <br />C. <br />State <br />T <br />O <br />EPA/Other <br />R <br />d, <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />S'iA <br />a. <br />J00 <br />b.. <br />6-11 14 <br />1S S eagL Handling nstryctwn nd Additional Information p <br />ltlrr §*i�` p .S.w pie H 4i t{ bt�R� 9 Fr � A vw ba4 ' 6 <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 />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If I am a large quantit'generatorj 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 economically <br />I the treatment, storage, or disposal currently, available to me which minimizes the and future threat to human health <br />practicable and that ave selected practicable method of present <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 />Painted/Typed NameSignature <br />: �" <br />Month, Day ,Yeori <br />r: •fit <br />f' <br />I mow. <br />T <br />17. Transporter 1 Acknowled emeWof Receipt of Material's X * '" <br />RPrinted/TypeclActme <br />f `'x' <br />Signature _. <r" _ <br />A <br />Month" Day Year,_ <br />S�p <br />f� ' 4w�`� <br />r F <br />8 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />20. Facility Owner or Operator Certificationof receipt of hazardous materials covered by this -manifest except as noted in Item 1-9. <br />T <br />Printed/Typed,,plame' ,' <br />Signature <br />Month Day Year <br />Y <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) Yellow GENERATOR RETPA!NEl <br />EPA 8700-22 <br />