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awn of AgencySee Insh ns of a o. at r <br /> ;arm . 0 9-30-96) Sacramento,Coworwo <br /> %ase print or type. Form designed for use at oft(12pitcfu}y wwriter. <br /> UNI H R S ator s US EPA 10 No. Document 2• 1 <br /> b in do slesded aroo; <br /> not by law. <br /> WASTE MANIFEST of <br /> 3. s A A. ; <br /> : .J <br /> B. s ID <br /> r . <br /> 4. Goneralces Phone <br /> i t . <br /> 3. Transporter 1 Company Norm b. US EPA ID Number C State TrardpwWS 0 * :;. <br /> 7. Tronsp I oder 2 Company Name S. US EPA ID Number E. State Tronspartees ID PK <br /> J- <br /> F. Traosporlet'SIFfione <br /> z 9 _ Sita A s. 10. US EPA 1D G. f + ss - <br /> Qi G <br /> ID <br /> Iq 1.51 <br /> sk <br /> I fir <br /> 12. Containers 13. Total 14. <br /> z 11. U.S DOT-Description(including Proper Shipping Nome,Hazard Class,and ID Number) <br /> NO T <br /> 3 U/ ad• �r f t rM1. I �� sy A` s <br /> E <br /> N. <br /> b. 7 z` <br /> d R ;1- <br /> A <br /> ® Skft <br /> M <br /> Ll <br /> w d• <br /> U <br /> J. A for Above K. for W g, <br /> ® b• <br /> c. d. <br /> Z <br /> Q15. Special Handling Instructions and Additional Information <br /> H <br /> Z <br /> to <br /> F <br /> 16. GOMRATWS : I hereby declare that the contents of this consignment aro fully and accurately dexTibed above by proper Shipping and ae <br /> UU4pacited,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and <br /> If I an a large quantity generator, I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree 1 have datennined to be <br /> future <br /> C ble and that I have selected the practicable method of ,or disposal currently available to me the and <br /> boo <br /> threat to human health and the environment,OR,if I am o smolt generator,I have a good faint effort to ary the <br /> q� wade management method that is available to me and that I can afford. <br /> V <br /> prin"Oyped Name <br /> T 17. Tganumler I Acknowledgermod <br /> _ of Receipt of Materials <br /> RYPed 1401mo t< t r Signature ) <br /> P 18. IraM2ft 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Signature Day Yaw <br /> O R <br /> y19. Discrepancy Indication Space <br /> V P <br /> A <br /> Z C <br /> 1 <br /> 1 20. Fod w Certification of receipt of hazardous materials covered this m exceptas noted in Rem 19. <br /> T /T Signature / Day? QYew <br /> h <br /> DO NOT WRITE BROW THIS UNE. <br /> DTSC=2A(9/94) I;,.y ;;FNM4 THIS (CVW TO GENERATOR WITHIN 30 DAYS. <br /> EPA 22 e,..., a••n:::r„er? hrv�tsrSoe s waste +o: out-of <br /> „ ,•„.=r,K•�u cous at!fits zoov and sand no DTSG 30 days.) <br />