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State of Cali fornia^Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9.30.99) 1 ,H „See, In $t� LJCtlOnS on bac age 6. <br />„i._ Please print or type. form designed for use on elite 11 2 -pi pewriter. - r �^ ! , <br />ii <br />Department of Toxic Substances Cot <br />DO NOT WRITE BELOW THIS LINE.. <br />OTSC 8022A (1 /99) D, 'i >, <br />EPA 8700-22 <br />UNIFORM HAZARDOUS <br />" ca <br />1;. Generator's US EPP.ID No. _ Manifest Document No. <br />fr I1.QA <br />2. Page 1 <br />v, wuwrma <br />Information in the shaded areas <br />WASTE MANIFEST <br />is not required by Federal law. <br />r, <br />2 4 1, <br />of 1 <br />3. Generator's Name and Mailing Address <br />A. Sfate Mantle{t QocUmentlurtber " <br />Lhl UTA <br />b tl S . SI`AN 151�fiIS :� i".'i' <br />B. State <br />4. Generator's Phone (s UIW, . <br />a, - <br />N <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C State Transporters { rve r :* <br />0: TFanspo r rs Phone <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E $tate Trgo otters ID Re erved ; wvJ <br />Air <br />J <br />we4,... <br />QF <br />J <br />TranaporteF's,Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G ' State Fpulf s IDk"- N rte. <br />r rrS <br />H+ Facility'.+phano <br />. <br />!12• <br />J <br />Containers <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number - <br />P f 9 P PP 9 ) <br />13. Total—4:>Unit <br />l d; <br />No. <br />a. <br />Type Quantity Wt/Vol <br />1. Wagte.Numbe"r^ <br />C <br />1•:^;, t,StS".'i; SI)U1J.�i HYl)RUnIGB 50L��Oir fi liti'fl?9 ?GII QQ(0081) •s"gG(i54) <br />t <br />t; s <br />'> G <br />E <br />a r✓ <br />T1 Fd S y 4 G <br />N <br />°o E <br />b. t> <br />— <br />ay srl�t� j iTlib j"f 1fi %^ �, <br />�PA�¢f e1 3 <br />a A <br />> T <br />C. <br />� <br />O, <br />are � ,�. r' •� <br />a <br />LLLL <br />d <br />4 <br />i` <br />3 <br />J <br />F� :.r <br />s <br />> <br />J. Additional Descriptions for Materials listed Above <br />aj 341Eii-�� SODIUA HTD�.O%IDS SOLUTION <br />Ky Handlm Codes for Nr rtes (s{Iev k «� <br />�' -� � <br />- WAT12-3 (1) � <br />, a h fx <br />f <br />c; . p <br />15. Special Handling Instructions and Additional Information <br />CALL (811) 567-7455 <br />t <br />ar.:._ ��:ktiirun .��tYp:;t„ti'i.><1 l;Li);'iiifiC. sfil6i;Etti�Y s�SPfl�iSl: PBOH[; (fiS3t 5a7-7455. <br />t <br />i <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shiping name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway <br />according to applicable <br />international and nationagovernment regulations. <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of <br />procticable and that I hove selected the practicable method of treatment, storage, or disposal currently available <br />and the environment; OR, if I am <br />waste generated to the degree I hove determined to be economical <br />to me which minimizes the present and future threat to human healthly <br />a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste monoIgement method that is <br />available to me and that I can afford. <br />Printed/ITy d Name _ Sl g W pa "� <br />` (� <br />' (vlonth. Da Yearr- <br />(T/ <br />-u <br />U ; 0 �. <br />T <br />R <br />17. Transporter 1 Acknowled ement of Receipt of Materials <br />A <br />N <br />Printed/Typed Name Signature <br />, <br />Month Day Year <br />0 <br />8 <br />18. Transporter 2 Acknowledgement of Receipt t of Materials <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />19. Discrepancy Indication Space <br />F <br />A <br />t <br />i <br />1 <br />L <br />1 <br />'Printed[Typed <br />20. Facility Owner or Operator Certification of recei t of hazardous materials covereJ,6y this manifest exce t as noted in Item"19. <br />T <br />Y <br />Nome Si na re i <br />_ g 3u Da Year <br />_6r- .— %` ._ ..l ✓ '_I,j' s- //'.f'�.11�. _..� '%\•^ ._-'c'LpJ 7����'�I00jP <br />DO NOT WRITE BELOW THIS LINE.. <br />OTSC 8022A (1 /99) D, 'i >, <br />EPA 8700-22 <br />