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- "T'T _.1•R,;;,i. :.. .t'r.q},r:..., , em+., .,> .„.. x-ss:kC.,. .:.:"fie-.�p ;,. M.�b oi�F,ge.' •-tn.>. <br /> Stale of Colifdrnia—Environmental Piobttion Agency ` v f <br /> Form App r ved OMB No.2050-0039(ficpires 9.30.991 8 'EIS Y f� I) 1 yr rymeA}(qf Tsutje Substances Ggptral <br /> Please .n or type. form designed for use on elite 112 p}feh ricer. � / ( rj Scagmgalg,Pglifornio <br /> 00 <br /> c1. Generator's EIS EPA ID No. nifest Documas)Na Z }'gee T f nfgrmafiop the sftaded areas <br /> UNIFORM HAZARDOUS § < { ig pot requir (ty fedRrQl law.. <br /> WASTE MANIFEST 1 '6 a( ' <br /> 3. Generator's Name and M�siling Address ' <br /> L'*ITA Pf AT1W',, INC. <br /> o 818 S. �,t"1 A NISLAII.9 b►"'17Et1F,T <br /> a. Generators Phone(1ftY.'lK" CA 95206 (209)948-2768 <br /> CV 5. Transporter 1 Company Nome 6. US EPA ID Number <br /> LO <br /> ao <br /> 0 21 St C22+i'11.IRY M1 A RI 0 ell ell 1. 2 <br /> 7. Transporter 2 Company Nome 8. US EPA ID Number <br /> Ln 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> W2 215t Century DII ' <br /> O 2095 an Dr. East <br /> U. <br /> U <br /> 12. Containers ” 11a.110 1 s A • n <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> X HA8AMS WASTE, SOLID, 4,O.S.I .(1106) 9 AA3177 PG111 4()(18) ; .0 <br /> 3 G KRG 0 711 C> G3 P <br /> o N b <br /> co E RQ HAXAMS WASTE, SOLID, N.O.S. (CORfR1I011) 9 U3177 P0111 <br /> N R RQ1,D117► KRG0 71) CA`, H <br /> .1 AIWI-0610 <br /> A _.r. <br /> o Tco <br /> e( <br /> R <br /> d. s ° <br /> Uj <br /> ZJ. Additional Descriptions for Materials Usted Above. en_4 <br /> O x) X94113-16 - F886 116!'R4CALR . 44AI413 (1f 61 341il -N ` Imo! . . <br /> W <br /> 011 (2) -•,: <br /> 0 15. Special Handling Instructions and Additional Information " <br /> Z WEAR PROPER PROTECTIVY CLOTHING, SIIli GUCY 196PONSE PKINE (811) 567-7455. <br /> W - <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and cceurately described obov®byproper,shtp fng.game and are elassifil pocked, <br /> Vmarked,and labeled,and are in all respects in proper condition for.transport by highway according to applicable;igterpatiRnof'gnd nrs c �tOfa tpant Teguigpona <br /> -�+ If I am a large quantity generator,1 certify that I have a prorom in plateyo reduce the volume and:tozieily of•wDIt4 gotieraterf to tlse;dpgrs ;have deto►mined.to lse'swnomitally <br /> Hpracticable and that 1 have selected the Practicable method of treatment,storage,or disposal currently avadgble.to gte which.mtgtmtzes tlw rosen)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.w,d3%general{ort RD a!!(eaR p est wasta.mP? emetlt4method that is <br /> ceavailable to me and that I can afford. ' <br /> P d/j Name t _.. Mgath Day Year <br /> Z I. :l: - <br /> Ur R 17. Transporter 1 Acknowledgement of Recei t of Materials - <br /> tl Printed/Typed Name Signature ° { ,� p�y <br /> w R th iA TYear <br /> i 01- <br /> U- 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed d Nome Signature C`• nth/ "`pay Year <br /> N R O Ft"A) ri✓ VZL-�"t� �*- <br /> (Qj 19. Discrepancy Indication Space <br /> Z F <br /> A ,. <br /> L , <br /> 1 20. Facility Owner or Operator Certi'Eation of receipt of hazardous materials coverid by 1 is manifest ezce a no <br /> 1 P'nnte�/Typed Name 1 j S1 ature / - Mo th Day— Year <br /> DO NOT,'•WRITE BELO.V1 'THMAINE. <br /> Yellow: TSDF SENDSvTHIS+COPY.�'TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-ol-slote, <br /> EPA 8700-22 produce coni pleted copy of this copy and surd to.DTSC within 30 days.) <br /> , <br />