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mdronmemal Protection Agency c <br /> ,AS No.2050-0039(Expires 930-96) See Instructions on back of •ge 6. Department of Toxic Substances Control <br /> ,pe. Form designed for use on elite(12pitah) 'tea Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Dent No. 2. Page 1 ].formation in he shad <br /> Document ed areas <br /> is not required by Federal law. <br /> WASTE MANIFEST of <br /> 3. Generator s Name and Mailing Address A. Store Manifest Document Number <br /> 95673607 <br /> - - B. State Generator's ID ' <br /> In 4. Generator'.Phots ( ) 5 I' 11 1 11 Ise I I I 1 I_ <br /> 3. Transporter 1 Company Name 6. US EPA ID Number C. Stab Transporter's ID <br /> M Transporter',Pltosse <br /> Q7. Transporter 2 Company Nome 8. US EPA ID Number E. State Transportsr's ID <br /> IFU <br /> _ F. Transporter',Phpne _ <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Sfax Facility's ID <br /> 0 -' H. Facility's Phone <br /> Q ' <br /> +r U <br /> 12. Containers 13. Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shipping Name, Hazard Class,and ID Number) No Type Quantity Wt/Vol 1. Waste Number <br /> T/ 1=— Sets t <br /> No <br /> 00 E N b. sae <br /> m <br /> REPA/Other - <br /> A <br /> sraro <br /> T a' <br /> 0 EPA/Od;it . <br /> R <br /> w state . <br /> Z d. <br /> U EPA/Other <br /> to <br /> N <br /> Z1. Additional Descriptions for Materials Usted Above K Handling Codes far Wastes Listed Above <br /> :SFIY'�' 9S'F a• Lr4 b' <br /> N <br /> oc <br /> K <br /> c. d. <br /> Q <br /> O 15. Special Handling Instructions and Additional Information <br /> Z <br /> 2 <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, <br /> Q 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 /> U <br /> J If 1 am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of wash generated to the degree I have determined to be <br /> economically practicable and IfIN I have selected the practicable method of treatment,storage,or disposal curremy available to me which minimizes the present and future <br /> 11 OR, N I am ti small method <br /> treatment, <br /> I have made a good faith effort to minimize my waste generation and select the best <br /> N threat to human health and the environment; quantity generator, <br /> z <br /> wastes mann ement method that is available to me and that I can oflord. <br /> Signature <br /> r Month Day Year <br /> O Primed/Typed Name 9 <br /> is <br /> Z 1 17. Transporter 1 Acknowtsd-emen{of Receipt of Materiab <br /> (� A Printed/Typed Name _ Signorture _ Month Day year <br /> S <br /> w S _ <br /> P <br /> ty 0 .18. Tram e 2 Acknowlad emelt of Re<ei f of Materials Mardi, Day Year <br /> W 1 Fooled/Typedd Name Sigrwture �—` (-. (.. <br /> F <br /> O E t / [ ..Arm. s r t' <br /> N 1 .'Discrepanry Indication Space _I <br /> Q F <br /> U A <br /> Z C <br /> I <br /> E <br /> 1 20. FacilityOwner or Operator Certification of racer t of hazardmaterials aterials covered 6 this manifest except as naed in Mem 1 Month Day Year <br /> T Primed/Typed Name Signature <br /> Y a ri <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/95) <br /> EPA 8700-22 <br />