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State of California—Environmental Protection Agency <br />S@@ II15$rUC$I011s back( Qa9q 6. <br />Form Approved OMB No. 2050-0039 (Expires 9-30-9OI1 Department of Toxic Substances Control <br />please' Pont or ty Form designed for use on elite (12-pitch) fypewriter. .. Sacramento, California <br />UNIFORM HAZARDOUS <br />1. Generators US EPA ID No. ` Manifest Document No. <br />' <br />2. Page 1 Information in the shaded areas <br />is not required by Federal law.. <br />WASTE MANIFEST ' <br />f 3 3 ? <br />. 'of 1 <br />3. Generator's Name and Mailing Address FIC +t r. <br />Vat <br />n <br />9� <br />h <br />4. Generator's Phone2W -134-M <br />00 <br />�j <br />5. Transporter 1 Company Name b. US EPA ID Number <br />O <br />OO <br />GAESW 490 2 2 <br />Q7. <br />Transporter 2 Company Name S. US EPA ID Number. <br />U <br />. <br />Q <br />9. Designated Facility Name and Site Address 10. US EPA ID Number ' <br />o <br />'fit ' 'ku 'p 7-185-01 <br />5050 SALIM BLVD <br />aSALIDA,CA <br />95360 Mogog19q8 <br />(J <br />`i <br />Z <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers 13. Totol 14 Unit <br />No. T Quantity Wt/Vol':, <br />X) WA=- <br />3 <br />. G <br />1.993 iI { 01) <br />. ) b <br />00 <br />EM, <br />b <br />L a. <br />DM G <br />N <br />R <br />R } ?A1760 PGIII <br />a 2, <br />d <br />DON) (ERG960) <br />c3.. <br />ao <br />T <br />Q <br />c <br />3a <br />LU <br />Z <br />d <br />U <br />LU <br />Z' <br />0 <br />CL <br />LLJN <br />tY <br />Q <br />Z_ <br />Q <br />15 Special Handling Instructions and Additional Informafion:;1 11 <br />a <br />r2. 703--8 4660 24HR <br />. � gg gr�� i <br />IDOT# Ar 5i3 ii+ <br />-v <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment'.`are fully and accurately d* ed±;above by proper shipping name and are classified,,: <br />packed, marked, and labeled, and are in all res m pro r condition for transport b highway accordi to applicable federal, state and international laws. <br />P respects ' P pe P Y 9 Y ^g PP , <br />If I 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 <br />—' <br />economically practicable and that l have selected the practicable method of treatment, storage, or„disposal currently available to me which minimizes the present and future <br />N <br />threat to human health 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 s' <br />waste management method that is available to me and th1 1 can afford. <br />Ix <br />11at <br />11Q P /Typed No <br />S' re <br />Mo Day Y <br />Z <br />t <br />17. rfer I Acknowledgement of Receipt of Materials <br />L <br />N <br />Printed/Ty ed me i <br />Signature <br />M Day Y r <br />w <br />S <br />j( <br />�2 <br />P <br />: <br />>. <br />18 Trans iter 2 Acknowled ement of Receipt of Materials <br />W <br />f <br />Printed/Typed Name . <br />Signature <br />Month Day Year <br />LL <br />N19. <br />Discrepancy IndicationTSpace <br />Q <br />F <br />U <br />A- <br />Z <br />C <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials <br />covered b thl manifest except as noted in Item 19. <br />YPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />y <br />._• <br />DO 1OT �11IT,BELOW THIS LINE. <br />r <br />DTSC 8022A (7/92) <br />EPA 8700-22 Yellow: GENERATOR RETAINSr <br />