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of 5:aWarnio—Emironme al Proticfion Agency,, <br />Fjjftn Approved OMBfto. 205r -003p (Expires 9.30,A6) Seo Instructions on back of <br />Pkease prm4 orrtype. Fonar i4agned for use on stint (I2pifch) r. <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. <br />WASTE MANIFEST tilr A 21 7 1,1 1 8 13! <br />3. Generators Name and Mailing Address <br />� �w.: / � .S' �^�� �r•iR .� �� e? r �fc . tet. z <br />C4 <br />to 4. Generator's Phone (S!(t) { �— r (_r, <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />, <br />J `trident Truck Line ICIAID1918 2141814131710 <br />7. Transposer 2 Company Name 8. US EPA ID Number <br />Q <br />�►i" I I I I I I I I I I I I <br />6• Department of Toxic Substances Contr- <br />Socramento, California <br />T. Page 1Information in the shaded areas <br />is not required by Federal knN. <br />of Z <br />14. Unit <br />O 15. Special Handling instructions and Additional Information <br />Keep away from sources of ignition, Always wear hardhats when working arolnd <br />Z U. G. S. T. 'a 24 Hr. Contact Naive.,AgQ5g-f , -L ' & Phone.._'! 1Z_^ <br />w <br />x <br />r 16. GENERATOR'S CERTIFICATION: 1 hereby declare that Lhacontents of this consignment are fully and accurately described above by proper shipping none and are classified, <br />U packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />J –+ If 1 am a large quantity generator, i certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br />FL economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future <br />N 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 generation and select the best <br />Ix waste management method that is available to me and that I can afford. <br />}O Printed/Typed Name Signature /j Month Day Year <br />21, <br />Z T 17 Tran Fr 1 Acknowled eR—;M „ f M,. e—l. <br />() <br />p <br />Printed/Typed Name <br />Ix <br />LU <br />N <br />P <br />w <br />0 <br />18. Trans porter 2 Acknowled om <br />Printed/Typed Name <br />K <br />O <br />1 <br />Uj <br />44 <br />19. Discrepancy Indication Space <br />Q <br />U <br />FA <br />Z <br />C <br />I <br />L <br />120. <br />FacilityOwner or Operator C <br />Printed/Typed <br />T <br />Name d/ <br />DTSC 8022A (1/95) <br />EPA 8700--22 <br />Signature <br />Signature <br />Month Day Year <br />–i, Id I / I ["1 <br />Month Day Year <br />I I I I 1 <br />Month Day Year <br />3 '2l 2 1 G.71gi' <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />produce completed copy of this copy and send to DTSC within 30 days.) <br />