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;Eb <br />State of California—Environmental Protection Agency <br />Form'Appr`pved OMB No. 2050-0039 (Expires 9-30-99) <br />Please print type. Form designed for use on elite (12 -pitch) type <br />O <br />L0 <br />L0 <br />N <br />N <br />tn <br />00 <br />O <br />O <br />f J <br />L <br />�Q <br />12 <br />�a <br />L: <br />f- <br />3 <br />c� <br />C <br />a <br />a <br />C, <br />C, <br />CC <br />a <br />LL <br />H <br />L <br />LL <br />L <br />v <br />L <br />U <br />U <br />U <br />l <br />F <br />L <br />Ll <br />F <br />F <br />k <br />See Instructions on back of pCo.,1^•'� " ` Department of Toxic Substances Control <br />Sacramento, California <br />DO NOT/WRITE BELOW THIS,LINE. <br />2004 JUL 14 PM1:1 r <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />22A (l/99) i' (Generators who submit hazardous waste for transport out-of-state, <br />DTSC 80 <br />EPA 87022A produce completed copy of this and send to DTSC within 30 days.) <br />6.3 <br />1. Generator's US EPA ID No. Manifest Document No, <br />2. Page 1 <br />Information in the shaded areas <br />law. <br />'UNIFORM HAZARDOUS <br />is not required by Federal <br />WASTE MANIFEST <br />''' $ � ` �91317141ro, aI aof <br />. <br />3. Generator's Name and Mailing Address <br />*a <br />A. State Manifest Document Number 4ju <br />'El"" an R rte on <br />B. State Generator's ID'- <br />^' f '_ x '_' t 7t�i(1 ,3 _i)(};1, Sar< PafT°lol) - '.,A f�4r-5K� <br />A. Generator's Phone ( '�2)5 JrJ"i•wJ t rt ;f(11. i�c'g3= `"..1't%t <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporters ID [Reserved.] <br />ICIp 1 $ <br />s <br />D. Transporter's Phone (91 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />x-224 <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />H. Facility's Phone <br />678.5692 <br />e riF3 iaa' <br />° m 4 7163 <br />11, US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />. <br />State <br />a <br />L.M"St:v s. . i`J,i-`.2.2111,, rP- 01 , F R $ f .' .. <br />_). <br />i6 <br />EPA Other <br />E <br />®" <br />State <br />b <br />N <br />E <br />EPA/Other <br />R <br />A <br />T <br />c <br />Ft <br />O <br />-er <br />R <br />li <br />d. <br />State <br />i <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />f 1 Z, ' p0e ]135t,iilTio.' <br />a b <br />+ <br />C. <br />d. <br />n j �-yI JtT g q [� <br />f�h:(t§t1076i1(1L'd Addy{li,#Jnfk'f.^: C: af1�.'�I`If`11(( ei.Ct4.'.-t1f3}"e'tt)t"tit9 �t*Jji{id 3,. i, <br />OF GE'34CY CONT C' nn c- CCN at 1-800-4-124-9300 <br />yt�rx, <br />S1- 1 i, ' up, ad' arNSs. _x...,.::t y:D4? t;rj�% 1,1%t ).if1i:(°:(61 R',oa(' r'i(f�l. ,?f 1? .. -a. ; :j1:£t'. <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by'Proper shipping name and are classified, packed, <br />marked, and labeled, and ore in all respects in proper condition for transport by highway according to applicable international and national government 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 waste generated to the degree I have determined to be economically <br />treatment, disposal currently available to me which minimizes the present and future threat to human health <br />practicable and that I have selected the practicable method of storage, or <br />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 waste management method that is <br />available to me and that I can afford. n <br />Printer(/T ed Namcf g <br />Signature , <br />Month Da Year <br />> Y <br />v T <br />17. Tra`nsoorter 1 Acknowledgement of Receipt of Materials " <br />R <br />Printed/Typed Name- <br />Signature'.- <br />Month Day Year, <br />S <br />r <br />P <br />p <br />18' Transporter 2 Acknowledgement of Recei f of Materials f' Y <br />TPrinted/Typed <br />Name <br />Signature <br />Month Day Year <br />E <br />R <br />L <br />19. Discrepancy Indication Space <br />F <br />= A <br />f' <br />r, r <br />, <br />20. FacilityOwne or O er a ert+fication 0, cei t of haz dous <br />lslcovereclby this rrTanifesY'ezce 1 as no(eef'tn Item 19. <br />I <br />T <br />Printecl�Typed Name ! <br />Si�natur ` r !r <br />onth P Day P rYeaY`r <br />DO NOT/WRITE BELOW THIS,LINE. <br />2004 JUL 14 PM1:1 r <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />22A (l/99) i' (Generators who submit hazardous waste for transport out-of-state, <br />DTSC 80 <br />EPA 87022A produce completed copy of this and send to DTSC within 30 days.) <br />6.3 <br />