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Form Approved OMS No 2050--6039(Expires 9 30 91) Toxic Substances ControlDivision <br /> Pleaae print or type (Form designed for use on&fete(12 pitch typewriter) Sacramento Calitornra <br /> t Generator s US EPA ID No <br /> UNIFORM HAZARDOUS DocManifest 2 Pape 1 ument No Information the shaded areas <br /> WASTE MANIFEST 4 d `^ 1 )ti Iniof I is not required by Federal law <br /> 3 Generator s Name and Mailing Address A Slate Manifeg Document Number <br /> 8131870B State Generators!D <br /> 4 Generator's Phone <br /> 5 Transporter 1 Company Name~ a US EPA ID Number C State Transporter s ID <br /> r. I D Tranaportars Phone <br /> C', <br /> to <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's ID <br /> 1-1 !��AfN1 y�4 I JJ� I I F Tranaporters Phen <br /> 9 Designated Facility Name and Site Address 10 US EPA D Number G State Facility's ID <br /> H t S�tl, <br /> v,�v .4tC�f45✓SZzo �4 �45 Ili 9410 ity a Phano <br /> H. Facility <br /> C0:5 A nI ►(— -A P OCO— 1 <br /> 2 12 Containers 13 Total 14 I <br /> OLL 11 US DOT Description(including Proper Shipping Name Naxard Clasa and ID Number) Quantity Unit Waste No <br /> m No I Type Wtfvol <br /> "f U a State <br /> 00 G zz <br /> q <br /> ).- <br /> N I �lljh C t1 ! f EP4rOther <br /> E t i' Stats <br /> o R <br /> Go Go T EPA/Other <br /> Q O <br /> V R e <br /> State - <br /> 8 <br /> m <br /> EPA/Other <br /> S d I I I :: <br /> State <br /> Z <br /> U 1 1 FPA/Other <br /> tit <br /> Z J Additional Descrptlona for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> O <br /> � ( o L a57e b <br /> a <br /> Q` - <br /> Q 15 Special Handling Instructions and Additional Information <br /> 2,12)9� <br /> Z Ifo t ot� ?rAedl vc �{�• <br /> I t <br /> J <br /> J <br /> a 18 <br /> U <br /> J GENERATOR'S CERTIFICATION I hereby dedare that the contents of this consignment are fully and accurately described above by proper shipping name <br /> J and are classified packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and <br /> Nnational government regulations <br /> If I 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 <br /> O to be economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the <br /> > present and future 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 <br /> U generation and select the best waste management method that is available to me and that 1 can afford <br /> Z <br /> LU Panted/Typed NameLy^� ��ln� wht�"�� Signature , p Month Day Year <br /> ix <br /> Lam <br /> WT 17 Tranaporter 1 Ackn wledgement of Receipt of Materials,-.��-k <br /> Z R h <br /> < A Printdt y ed Name Signa ur Monr Day Year <br /> " <br /> LL to <br /> 0 <br /> O P <br /> W O 18 Transporter 2 Acknowledgement of Receipt of Matenals <br /> UT Printed/Typed Name Signature Month Day Year <br /> 8 <br /> z <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 1 20 Facility Owner or Operator Certification of receipt of hazardous Materials covered by this manifest except as noted in Item 19 <br /> T <br /> Y rnied/Typed Name Signature Month Day Year <br /> DKS 8022 A(tt88) Do Not Write Below This Line <br /> EPA 8700-22 Slue GENE-RATCR SENDS THIS COPE TG DCHS WITHIN 50 ,DAYS <br /> (Rev 9 88)Previous editions are obsolete To P 0 Box 4%, Sc:cramento, CA 4--812 0400 <br />