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ate of California—Environmental Protection Agency <br /> xm Approved OMB No.2050-0039(Expires 9-30.99) See Instructions on back of6. Department of Toxic Substances Control <br /> ease print or type. Form designed for use on elite(12-pitch) er. & Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST <br /> IC-AiP;atioc7i;Aoi;?[::;ZIQI--7iI 5101011of 1 <br /> 3. Gentor's Name and Mailing Address m <br /> Per .$tv �/S7�/C3u.`fe oN DPOY—SAN�"O�Q- Jv S <br /> -BOX 960 001 &01 S-108 reG�;;era <br /> A. Generator s one " <br /> Fe <br /> S. Transporter 1 Company Name 6. U5 EPA ID Number CL.S�t�a,M rart3pQ[tlPS-10" <br /> 77 <br /> TDI r1GLIT I�1 1/+VI IA/Ct.^ /'+ A ^ A A A • A / A ' A ^''� `�' �„a' $nr " •'~� `* `•Y' _?:" +`<> <br /> t rXtucry t Ir rtue.nutvG0H LJ V 0 A 4 0 4 3 l'U tY,Trmi°s"'" r'sPFlone,' <br /> 7. Transporter 2 Company Name 8. US EPA ID Number <br /> Mf'z'ran6 �.. > ry <br /> tF?fLy a Ffi jNeme and Site Address 10. US EPA ID Number k <br /> CtCII+T.? tY IIV6i, s <br /> 255 PARR BLVD ,b <br /> RICHMOND, CA sasol A 01914,6161319 2 "' ° <br /> 3� 5 0-235-1393•= <br /> I w- .�:'� „l-...:�' ' 'h'4-fid <br /> 12. Containers 13. Total 14 Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> No. Tye Quantity Wt/Vol Waste umber .x, :A <br /> WAS I E EMPTY $fafe� �2 ei <br /> P <br /> Non-RCRA hazardous waste solid TP EPA/OtherNONE <br /> G <br /> E <br /> 6. State s ' <br /> E <br /> EPA/Other,` <br /> R ,, a <br /> A <br /> T �• state <br /> R EPA/Other' <br /> d. State <br /> EPA/Other_, <br /> J. Additional Descriptions for Materials Listed Above t J iC Handling Codes for Wastes Listed Above <br /> QTY EMPTY STORAGETANK€S <br /> BEEN INosv <br /> . <br /> rt . <br /> 15 LBS DRY ICE PER 1000 GALLONS CAPR� `°" °`- "`a �;` d <br /> �?a�� {�.5 � �` Te�f.�{.�� '�`•st a � °'�- gk nY A <br /> ear. Fopr a have-® t eng when handling- a <br /> L�f�Yck{zo ! <br /> 24 Hour Emergency Telephone Number: (�-Dcij <br /> 24 Hour Emergency Contact: 9es�'a- Ip —�0�yTv ERG 171 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents 61 this consignment are fully and accurately described above by proper shipping name and are classified,packed, orig <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 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 economically <br /> practicable and that I hove 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 /> Printed/Typed Noma Signature Month Day Year <br /> T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Printed/Typed Nome Si tura Month Day Year <br /> Rvim.tel- Z Z <br /> S <br /> 0 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> E <br /> R <br /> F 19. Discrepancy Indication Space <br /> A <br /> C <br /> i <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> T <br /> DO NOT WRITE BELOW THIS LINE. <br /> TSC 8022A (4/97) White: TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> PA 8700-22 To: P.O. Box 3000, Sacramento, CA 95812 <br />