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ti @ 01 <br /> State Ofat•.alifAgency <br /> OMB Na. 9 9ao 96) Instructions on back ofjk�.print or teFmm designed for use on efib(1?•p")I <br /> ® UNIFORM HAZARDOUS 1. Anadiod <br /> aror s US EPA ID No. Manifest Document 2 is <br /> dw <br /> WASTE MANIFEST �y 3 717 <br /> 3. GenercyUp�Nott�e 'C ailing Addfe <br /> Ilcap 1j.2� t <br /> ®cf/-So <br /> � e leM 1N <br /> 2O ( <br /> t. P Scwt Sn`�S <br /> A. Generator's Phone (�! ) tT 2 453 <br /> S. Transporter 1 Company Name 6. US EPA ID Number <br /> e2!cAr.5- At C-- <br /> 7. Transporter 2 Company Name 8. US EPA ID Number <br /> Q <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G <br /> r, pwl F <br /> 11. US DOT Description C—tuding Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total. 14. Unit <br /> No. T Quantity Wt/VOI <br /> c0 <br /> N b• <br /> R <br /> A <br /> T <br /> O <br /> R <br /> d. <br /> LU <br /> J for Matericiths Listed <br /> LU <br /> CK 7- <br /> 15. Special Handling Instructions and Additional Information <br /> _ _ <br /> .•fes.'. fir. ; '. C _. !1 �T.i`. _ t� t .lA .. � '�1 .a�i.: :'!�'�..E <br /> Q <br /> 7 v f� <br /> r 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and arc classified, <br /> J <br /> 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 I 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 1 have determined to be <br /> economically practicable and that I have selected the practicable method of treatment, ,or disposal currently available to me which minimizes the present and future <br /> Nthreat to human health and the environment;OR,if I am a small quantity r,1 ma good faith effort to minimize my waste g cf the best <br /> waste method that is available to me and that I can afford. TVxry <br /> P• Name Sig r Month o / Yom• <br /> cN�V 6 <br /> Z W 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> A Pri /Typed Name Sign re Month .INADay Year <br /> N p �- r l6 t <br /> t ' <br /> w 0 1 T 2 Acknowled meM of Rece17 <br /> i of materials <br /> A Printed/Typed Name Signature Mordh Day Year <br /> 1 <br /> E <br /> It <br /> 19. Discrepancy Indication Space <br /> VA - M•.,. <br /> C <br /> L <br /> I 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered this manifest exce as noted in Nem 1 . <br /> T Printed/T Name Sig Month Day Ye <br /> Y ( ar to �. b <br /> .e DO NOT WRITE BELOW THIS UNE. <br /> White: TSDF SENDS THIS COPY TO DISC WITHIN 30 DAYS• <br /> TSC 8022A (1/95) To: P.O. Box 3000,Sacramento,CA 95812 <br /> EPA 8700•-22 <br />