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State of,.W,ifornip nvtronmenrol Protection ginry.
<br /> F Qvecll No ?050-0039(Expire'9-3Q-90) See Instructions on back
<br /> Pleas®p n1 or type. I" desia*,&,A
<br /> gned forfuse o eLt�f i •(3itch titer, 467' Department of Toxic Substances Control
<br /> Sacramental California
<br /> °t 1. Generator's US EPA ll •l . Manifest Documen 2. Page, Inform tion t o shaded areas
<br /> UNIfiORM HAZyRDgS
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<br /> WASTE MANIFEST C_• ` t$ 9 5 ,2 5 fAdbr• r
<br /> 3. Genoratgr's Nome and Mailing Address
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<br /> A. Generator's Phone OPO( "ON (;A 95206 (209)948--2768
<br /> sfV 5. Transporter 1 Company Name 6. US EPA ID Number
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<br /> �yt'�"� 7. Transporter 2 Company Name 8. US EPA ID Number %w`- •"'
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<br /> 9. Designated Facility Nome and Site Address 10. US EPA ID Number
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<br /> s 0245 7777 RVFmF- SC)t9'I'M'I ¢ `
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<br /> 11. US DOT Description(including Proper Shipping 12 Containers 13 w
<br /> P ( g Pe ppin Name,Hazard Class,and ID Number) ;Total 14. Unit, .! .
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<br /> PQ WASTE COFEIOSIV'H LIQUID, ACIDIC.r I#01CUIC, X.O.S. {SOLFU$IC
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<br /> co E RQ UZAR"S MASTS, SOL10, k,Q,S. (CHROIIIUII) 9 NA3177 FBIII`
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<br /> J. Additional Descriptions for Materials listed Above
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<br /> 0 15. Special Handling Instructions and Additional Information
<br /> CALL (8#1) 567-7455 s'" _
<br /> Z ltr�R. PItGPE.R PBOTIsCTIV6 CLOTHINC. RgMIGUCT IRSPOMISB FHOI16 (891) 567-7455," „
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<br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propershfppfng name and are dassifiod,packed,
<br /> V marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable-iMknationaI and natio�gl gQvernmenf rogulatwns.
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<br /> -� If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity okwa;ta generated toahe degree I hove,determined,to be economically
<br /> V) practicable and that I hove selected the practicable method of treatment,storage,or disposal currently ovailable to mgwhich minimizes,the present And future,thisat to human health
<br /> oc and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my wash.generation,and salechth�6es�watt'management Method that 0 available to me and that I can afford.
<br /> Pri S e Si nature
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<br /> W T 17. Trans rter 1 Acknowled emenf of Recei t of Materials v
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<br /> y�J M Printed/Typed Nome Sign ture
<br /> w P ./y✓�/i, G��s /�7� �r - Mont Day Year
<br /> 0 0 18. Transporter 2 Acknowledgement of Recei f of Materials ® Q
<br /> TPrinted/Typed NomeUJ Sig tura _
<br /> N E Month Day Year
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<br /> 19. Discrepancy Indi alien Space O10
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<br /> cili Owner or O erot
<br /> 20. Faor Certification of receipt of hazardous materials covered 6l is monffest exce t as noted in 1 "19
<br /> Yed/Typ'ed Nome \ Signotur w•.. _
<br /> DO NOT WRITE BELOW TJIJI LINO
<br /> TSDF SENDS THIS COPY TO 1;ENERATOR WITHIN 30 DAYS.
<br /> DISC 8022A 11/99)
<br /> EPA 8700-22 (Generators who submit hazardous waste for transport out-of•stole,
<br /> Produce completed copy of this copy and send to DTSC within 30 days.)
<br /> ,AUG 12 ANI 1:12 S
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