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State of Cali forni Environmental Protection Agency fir' <br />Form Approv MB No. 2050-0039 (Expires 9-30-991 See Instructions Ori back of pa Department of Toxic Substances Control <br />Please,ar+.. o^ Noe. Form designed for use on elite (12 -pitch) type - Sacramento, California <br />O <br />Ln <br />V1 <br />N <br />CV <br />LO <br />O <br />O <br />I Q <br />V <br />.Q <br />'Z <br />C <br />i, LL <br />4 <br />�Z <br />H <br />3 <br />C <br />C <br />oc <br />a <br />C, <br />C, <br />C <br />C <br />ck <br />LL <br />t - <br />Z <br />LLL <br />LL <br />V <br />2 <br />C <br />d <br />V <br />LL <br />L <br />C <br />F <br />L <br />u <br />3 <br />t- <br />L <br />' DO NOT V/RITE BELOW NIS LINE. <br />Yellow: TSDF SENDS THIS COPY TOtdcls,AIRM <br />(Generators who submit h tate;DTSC 8022A (1/99) produce completed copy of th30 clays.) <br />EPA 8700-22 21�1�.�4 JUL 4 4 Pmt :1'� <br />U i'-1 �CG�'Y ors C <br />1. Generator's US EPA ID No. ' Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />a <br />is not required by Federal law. <br />WASTE MANIFEST <br />3: fi <br />of <br />J y_ <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number+ <br />B. State Generator's ID <br />A. Generator's Phone f - -. <br />519 -''yam:.^: -:1 d;t$dl <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID [Reserved.] <br />k2l}} <br />D. Transporter's Phone 176- 2240 <br />7. Transporter 2 Company Nome 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />"' .J -,�. •® s.. }I <br />F: Transporter's Phone t �r <br />s x.� <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />}1]i <br />H. Facility's Phone <br />( <br />-92 <br />56 <br />da,m <br />'° <br />11, US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />IA. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Type <br />a. <br />Ir <br />State <br />'IA2.1�j PGi]i i' t Ci#1 <br />EPA/Other - <br />rdr <br />G <br />' <br />�'° <br />.' 1. <br />.� t <br />E <br />b <br />State <br />N <br />E <br />EPA/Other <br />R <br />C. <br />State <br />T <br />® <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />" <br />K. Handling Codes for Wastes <br />Listed Above <br />i Id t'I;as_iaidtd)44:: �h�lit .g@P�;'dit1$�7114}�1R"S� 4T15E3sd}dfS&It <br />a <br />.'"""� °, <br />b. <br />C. <br />a. <br />15. Special Handling Instructions and Additional Information <br />`��exF C:si ,`1ar:dt ...�ff�,,,��tf9rJVP..� Dl6i#Os•tlVz v';CiCI "ilei :i31.}'cisf)it-atc,t'y )a3C)[Ot:tC7!? �'r?1E'i [1r11tC}flirt# <br />CONTACT: hem -Tel, Inc. at 1 -800-255-3924 <br />ii;!w4 rldfim?;s,' `. E'C', S[S:cki l', 90 01 I -M?. .,i1 Ro-d tot,'Vion ?- A 95. ,07 ,'S'J[:? 4 '.1 7 i 611 <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 are 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 />and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />i <br />practicable <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. I ` <br />Printed/Typed Name " j <br />Signa)it"r'eonth <br />t' ? <br />M Day -Year <br />t i <br />IL <br />t T <br />t <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />Printed/Typed Name <br />Signaturer.., ✓ <br />Month Day Year <br />S <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials' i <br />I T <br />Printed/Iyped Name <br />Sigpature <br />Month Day Year <br />t E <br />19. Discrepancy Indication Space i <br />E <br />• A <br />C <br />...�`\ <br />20. Facility Owner' or O eratootertifd icA n of receipt of hazardous materials covered by t s,manifest ex 't as' noted id Item 19. / %"1 <br />T <br />Printed/Typed Ndme ! ' <br />Signature i �' r <br />Aonth a ' i'c1ar j <br />Y` <br />' DO NOT V/RITE BELOW NIS LINE. <br />Yellow: TSDF SENDS THIS COPY TOtdcls,AIRM <br />(Generators who submit h tate;DTSC 8022A (1/99) produce completed copy of th30 clays.) <br />EPA 8700-22 21�1�.�4 JUL 4 4 Pmt :1'� <br />U i'-1 �CG�'Y ors C <br />