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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back o page 6. Department of Toxic Substances Control <br />Please print or type. form designed for use on elite (12 -pitch) typewriter. Sacramento, California <br />C <br />N <br />O <br />ao <br />CD <br />.a <br />N <br />v <br />0 <br />0 <br />CD <br />a[ <br />W <br />1� <br />Z <br />W <br />V <br />W <br />rA <br />Z <br />0 <br />in <br />W <br />a< <br />a <br />Z <br />O <br />Q <br />Z <br />W <br />F— <br />J <br />a <br />V <br />J <br />a <br />N <br />n <br />V <br />Z <br />W <br />L� <br />UJI <br />W <br />W <br />O <br />W <br />N <br />a <br />V <br />Z <br />DO NOT WRITE BELOW THIS LINE. <br />s <br />PA 8700-0-22 0 (1/99) <br />EYellow: GENERATOR RETAINS <br />EPA 87 <br />UNIFORM HAZARDOUS <br />1 • Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />WASTE MANIFEST <br />ii:'I _ <br />1 `'` � <br />is not required by Federal law. <br />P.. , �, <br />j J <br />of <br />3. Generator's Name and Mailing Address f / c <br />A. State Manifest Document Number <br />49-4 <br />State: "-s ID <br />A. Generator's Phone #: i 5244 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C.;$$ate Transporters ID ftgn2dj <br />t= est:' axs` t; �I 8 ° arr TF' r' its t r.f1t? <br />D: Transporters Phone <br />g..+E€riS <br />7. Transporter 2 Company Name S. US EPA ID Number <br />E. State Transporter's ID Reserved.] <br />F. Transporter', Phone <br />9 Desianated Facility Nam g anFf{Sde 00rpg ,,,t 10. US EPA ID Number <br />G. State f�aci11 s ID <br />r ..t <br />H. Facility's Phone ' <br />s�%t\X'r--f{{.. r�tll� i`,"l, Uay-.c - _ f-_ .q .• <br />�:. <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 />1. Waste Number <br />No. <br />Type <br />a• <br />-:•i-.'6 r ,a- t iF 7 `.:,-? t3 `, s i-- < ,°;�! 5; ° r <br />State <br />?'e _t <br />G <br />EPA/Other <br />E <br />N <br />b. <br />State <br />E <br />EPA/Other <br />R <br />A <br />T <br />C. <br />State <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />t'A'- "I fd i 1 t ro <br />a. b` <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />1')'4It: E.'t.s' i'4`. 1' T"e`Tr:brsa <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 oil respects in proper condition for transport by highway according to applicable international and national government regulations. <br />If I am a large quantity generator, 1 certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />practicable and that Ilselected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <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. <br />Printed/Typed Name <br />Signature <br />f Month Dayf Year <br />R17. <br />Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Printed/Typed Name <br />Signature a <br />YearP <br />=,MonthDay <br />f <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of aterials <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />It <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />L <br />( <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br />T <br />Printed/Typed Narhe <br />Signature % <br />Month. Day Year <br />DO NOT WRITE BELOW THIS LINE. <br />s <br />PA 8700-0-22 0 (1/99) <br />EYellow: GENERATOR RETAINS <br />EPA 87 <br />