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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 of page b. Deportment of Toxic Substonces Control <br /> Please print or type Form designed For use on elite f 12 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA ID No Man fest Document No 2 Page 1 Information in the shaded areas <br /> �_ is not required by Federal low <br /> WASTE MANIFEST `t &, of <br /> I 3 Generator's Name and Mailing Address A State Manifest Document Number 5 <br /> o ;;Wi#M 1I fO (t 0 i�'(� _• Ot K T 0N, ( A 9"1 le) is State Generator's ID 4 <br />�^ 4 Generators Phone( 704) I fjlll 1181 f3 y <br /> tV 5 Transporter 1 Company Name 6 US EPA 1D Number C State Transporters ID fReserved] <br /> in <br /> m <br /> D Transporters one <br /> to .it lig I (+II Al41 I ii �' I f ;� i (209) C�7�►Fi�� <br /> m 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporters ID Reserved] <br /> j J F Transporter s Phone <br /> U9 nF u i ,f�{ome Site Address 10 US EPA ID Number G State Facility's ID Y <br /> Q #�'�g_F{it g_itfW. 1r{ <br /> z 2 918 AI_M(All 1 1-1I� H Facility's Phorte <br /> +� <br /> `r 12 Containers 13 Total ld Unit <br /> Q 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Ty Quantity Wi/vol I Waste Number <br /> V <br /> Z a ;) �f.kA i l,�i -Alit 1(a 1�;, _ it i1Ei1 state `2' f <br /> sT_— 3 u II s a sit A I; M �� EPA/Other <br /> E b State <br /> C> N <br /> W E EPA/Other <br />�-4 R <br /> C14 A state <br /> o T <br /> 0 EPA/Other <br /> R State <br /> I F d <br /> Z EPA/Other <br /> V <br /> J Additional Descnphons for Matenols Listed Above K Handling Codes For Wastes Listed Above <br /> O a b <br /> v 0V .P' WA It I� <br /> U-1 <br /> � c <br /> J , y <br /> a <br /> 0 15 Special Handling Instructions and Additional Information <br /> r <br /> At`tVOI"I IAII VV tII t, Ihn- t:l ra1tll F._� <br /> IZ l �tii ��+°+i-N1, i It () 1,At`i (Alt)')Vi4' ii <br /> LU <br /> F <br /> 16 GENERATOR'S CERTIFICATION I hereby dadore that the contents of this consignment are fully and accurately described above by proper shipping name and are classified packed <br /> Q marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and notional government regulations <br /> V <br /> If I am a large quantity generator 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I hove determined to be economically <br /> practicable and that I have selected the ppracticable method of treatment storage or disposal currently avoilable to me which minimizes the present and Future threat to human heoitn <br /> and the environment OR iF I am a smakl 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 /> O Signature 1 <br /> Month Dayr Year <br /> I y PaSi <br /> Printed/Ty Name 1 { I <br /> w T 17 Trans orter I Acknowled ement of Recei t of Moternols <br /> IUr ! _ - Month Day Year ` <br /> W p Printed/LLJ Ty Name l Signatur �—+ <br /> w s >fl <br /> P 18 Transporter 2 Acknowledgement of Receipt of Materials r <br /> ts' � Month Day Year <br /> 0 T Printed/Typed Nome / S{gnoture <br /> ILU E <br /> / <br /> to R s� <br /> tel 19 Discreponcy indicohon Spoca <br /> Z P <br /> A _ <br /> C <br /> I #j!r <br /> I <br /> 0 Facile Owner or O araror Cerhhcation of recei f of hazardous materials covered b thu manifest except as noted i Item 19 <br /> rnted)Typed Name / Signature r — Month Day Year <br /> 1 DO NOT WRITE FLOW THIS LINE. <br /> IDTSC 8022A (1/991 Green TRANSPORTER RETAINS <br /> EPA 8700--22 <br />