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Form Approved OMB Nq 2050--W39(Expires 9 30 91) Toxic Substances Control Division <br /> Please print or type (Form designed for use on Wife(T2 prtch typownter) Sacramento California <br /> UNIFORM HAZARDOUS I Generator a US EPA ID No Manifest 2 Page 1 Document No inInformationinthe shaded areas <br /> WASTE MANIFEST I 1 1 L I I Lof is not required by Federal law <br /> 3 Generator's Name and Mailing Address .. A State M itDocument Number <br /> =—Fa= Sl4rly <br /> CA Mt lime ilftitV=th z P.O. BaX 280, Devic, C& 95616 B State Generators ID <br /> t Generator s Phone ) 412 1111 [ 1111111i <br /> .ci 6 Transporter I Company Name 6 US EPA ID Number C State Transporters ID <br /> ko D Transporter's Phone <br /> N I 181 Sao-s= <br /> 7 Transporter 2 Company Name a US EPA 10 Number E Slate Transporter'a I <br /> p I I F Transporters Phone <br /> m <br /> 9 Designated Facility Name and Site Address 10 US EPA 10 Number G State Facility s iD <br /> CheW cal Was 1=./ KettleREM TH13 FaC. R131 lepini alai 11 1:1:;l <br /> V 3521 OQId Skpli M RM d H vi e <br /> co Z Ktt1eMM 4..F' CA 432339 1r,1&1or1n1n1n1F;141r, ill 17 1 <br /> r.j LX 12 Containers --15 Totak 14 L <br /> 11 US DOT Descnpbgn pncludtng Proper Shipping Name Hazard Class and 10 Number) Quantity Unit Waste No <br /> C No Type W111Vol <br /> U a State <br /> _ Ammcm Waste solid Nos./ cmf-$/ M91M <br /> D <br /> EPA10ther <br /> ?i N Jet� <br /> E b State <br /> tti R <br /> Co T EPAIOther <br /> qr N 4 <br /> Q R c <br /> State <br /> m <br /> EPA/Other <br /> N d ' <br /> Stflte <br /> Z <br /> i U EPA/Other <br /> W <br /> Z J Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> a. 5011 Contadning PesUcla b <br /> z - <br /> 0 <br /> H 16 Special Handling Instructions and Additional Information <br /> Lu a. Profile 4SW-J 2527= C v I Z9 D <br /> Waar appmpx1ate pima= ve tlathf ng & rtspdsatar. Vbw bmn J <br /> J <br /> J <br /> a t6 <br /> U <br /> GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> and are classified packed marked and labeled and are in ail respects in proper condition for transport by highway according to applicable international and <br /> 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 toxicrty of waste generated to the degree I have determined <br /> 0 to be economically practicable and that I have seleMed the practicable method of treatment storage or disposal currernty available to me which minimizes the <br /> present and future threat to human health and the environment,OR,It I am a small quantity generator.I have made a good faith effort to minimize my waste <br /> c}] generation and select the beat waste management method that is available to me and that I can afford <br /> Z <br /> LU PnntedlTyped NameaTMINE WHITWORT3 AS Signa re . Month Day Year <br /> LU <br /> BANEXUPTCY TRUSTEE FOR CAL-FARM SUPPLY t✓r�.L l .c �k cJ l-tl OE 4 2 <br /> W RT 17 Transporter I Acknowledgement of Receipt of Materials <br /> Z A PnntedlTyped Name Signature Mont J]ay/ ea <br /> U. I <br /> O P <br /> to 0 to Transporter 2 Acknowledgement of Receipt of Materials <br /> UPrinted/Typed Name Signature Month Day Year <br /> E <br /> 2 <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> • L <br /> I 20 Facility towner or Operator Certification of receipt or hazardous materials covered by this manifest except as noted in item 19 <br /> T <br /> y I Printed/Typed Name Signature Month Day Year <br /> DHS 8022 A(1188) Do Not Wrrte Below This Line r,En c r+o IS <br /> EPA 8700--22 9E�e iE-1ATOR SENDS'ii1S C. Y T O DCHS WITHIN! 30 )A I <br /> (Rev 9 88)Previous editions are obsolete T. PC ?ox 400, Sacramento, CA 958+2 04CO <br />