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i <br />State of Colifomio—Environmental Protection Agency <br />Form Approved OMB No. 2050-x039 (Expires 9-30-94) See Instructions on back ofpa a 6. <br />Please print or type. Form designed for use on elite (12-pikcb) f r. <br />UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest Document No!W 2. Page 1 <br />WASTE MANIFEST AI iPT 1) 1?12f) f 9 of 6 <br />3. Generator's Name and Mailing Address d <br />,0 14FST I ONE FIJI=—,I--S <br />in <br />7` 30 WeST DANE, STOCI-''TQtI, CA <br />in4. Generator's Phone Po '- r}1 -! 70 <br />rb <br />p 5. Transporter 1 Company Name 6. US EPA ID Number <br />Dao i f'AI_. OiL t: tits 9 R2 4 17 2 55 <br />7 <br />Department of Toxic Substances Control <br />Sacramento, California <br />Information in the shaded areas <br />is not required by Federal low. <br />13. Total 1 14. Unit <br />go <br />0 15. Special Handling instructions and Additional Information <br />a APPROPRIATE PROTECTIVE CLOTHING <br />Z "EMERGENCY CONTACT e ( 2'1;19) 667-6692" <br />= SEE E.R.G. 31 <br />t- <br />16. GENERATOR'S CERTIFICATION: i hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br />packed, marked, and labeled, and are in all res m proper condition for transport highway according to applicable federal, state and international laws. <br />Q P P� � P Pe P by g aY 9 PP <br />U <br />If 1 am a large quantity generator, 1 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 />—' economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br />CL <br />threat to human health and the environment; OR, if I am a small quantity generator, I ave made a good faith effort to minimize my waste generation and select the best <br />tY waste management method that is available to me and that 1 can afford. <br />® Printe Signature,� Month Day Year <br />Z <br />T <br />If' rens orter 1 Acknowled a nt of Recei t of Materials <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />n <br />Printed/Typed Name <br />Si <br />ce a <br />s <br />9. Designated Facility Name and Site Address 10. <br />ua <br />1 <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Uj <br />E <br />Printed/Typed Name t <br />Sig ala <br />LL <br />O <br />>f <br />11. US DOT • s <br />Discrepancy Indication Space <br />"AZAPDOUS WASTE LIQL1ID <br />U <br />A <br />Z <br />C <br />I <br />t <br />I <br />20. Focility Owner or Operator Certification of recall# of hazardous materials <br />covered by thi: <br />Printed/Typed Name> <br />Signature <br />e <br />TT <br />to <br />`S` ➢ S� � � s l� -' { <br />9fiN <br />7 <br />Department of Toxic Substances Control <br />Sacramento, California <br />Information in the shaded areas <br />is not required by Federal low. <br />13. Total 1 14. Unit <br />go <br />0 15. Special Handling instructions and Additional Information <br />a APPROPRIATE PROTECTIVE CLOTHING <br />Z "EMERGENCY CONTACT e ( 2'1;19) 667-6692" <br />= SEE E.R.G. 31 <br />t- <br />16. GENERATOR'S CERTIFICATION: i hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br />packed, marked, and labeled, and are in all res m proper condition for transport highway according to applicable federal, state and international laws. <br />Q P P� � P Pe P by g aY 9 PP <br />U <br />If 1 am a large quantity generator, 1 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 />—' economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br />CL <br />threat to human health and the environment; OR, if I am a small quantity generator, I ave made a good faith effort to minimize my waste generation and select the best <br />tY waste management method that is available to me and that 1 can afford. <br />® Printe Signature,� Month Day Year <br />Z <br />T <br />If' rens orter 1 Acknowled a nt of Recei t of Materials <br />to <br />n <br />Printed/Typed Name <br />Si <br />ce a <br />s <br />4�e <br />ua <br />1 <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />Uj <br />E <br />Printed/Typed Name t <br />Sig ala <br />LL <br />O <br />It <br />N19. <br />Discrepancy Indication Space <br />U <br />A <br />Z <br />C <br />I <br />t <br />I <br />20. Focility Owner or Operator Certification of recall# of hazardous materials <br />covered by thi: <br />Printed/Typed Name> <br />Signature <br />TT <br />Month Dan, Year <br />l�J <br />Month Day Year <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (7/92) <br />EPA 8700-22 Yellow: GENERATOR RETAINS <br />