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..8No.2050.0039(6plres 9-30.94) See Instructions on back of page 6. Department of Toxic Sabstmcm Control <br /> rpe. form desigried for ase on ellro(12pihh)• -me, Sacraments,California <br /> UNIFORM HAZARDOUS "Ilrotor's US EPA ID No. Manifest Ducurn 1 1 2. Page I 1 Information In the shaded areas <br /> WASTE MANIFEST is not required by Federal low. <br /> of <br /> 3. Geircrafor's Name and Mailing Address A. Stole Manifest Document Number <br /> us , <br /> u) <br /> t` <br /> N 8..Stale Generator's ID <br /> h 4, Generator's Phone ( ) <br /> 00r�s <br /> a S. Tramportar 1 Company Name 6. US EPA ID Number C. State Transporters ID <br /> D. Transporters Phone _ <br /> U 7. Transporter 2 Company Name 8. US EPA ID Number E.State Transporters ID 414 J n - <br /> s <br /> Q - F: Transporter's Phone <br /> 9. Designated Facility Nome and Site Address 10. US EPA ID Number G. State Facility's ID - <br /> �Of F ` <br /> 0 <br /> H. Facility's Phone <br /> �U <br /> �Z 11. US DOT Description(including Proper Shi Nome,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> P ( gPF'^9 No. T QuantityWt/Vol I. Waste Number <br /> �~ a' State <br /> G EPA/Other <br /> o E <br /> wN Is. State <br /> 2 E <br /> R EPA/Other <br /> A <br /> gg T c- State <br /> O <br /> K R EPA/Other - <br /> w <br /> Z d. State <br /> w <br /> V <br /> w EPA/Oifter <br /> to <br /> Z 'd.Additional Descriptions for Materials Usted Abc a <br /> P' <br /> 0 K..Handling Codes for Wastes Usted Above <br /> � a b. <br /> J <br /> r 3, d' <br /> Z s <br /> 0 15. Special Handling In,tnn Knn,and Additional Information <br /> f <br /> Z <br /> Z <br /> W <br /> H ' <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> Qpocked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> V <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 <br /> Ceconomically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> N threat to human health and the environment; OR,R I am a small quantity generator, 1 have made is good faith effort to minimize my waste generation and select the best <br /> waste mores ement method that is available to me and that I can afford. <br /> 0 Printed/Typed Name I. SigiaNre ' Month Day Year <br /> U d <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W <br /> VrA Ported/Typed Name Signature Morph Day Year <br /> W .� - <br /> WP <br /> O 18. Transporter 2 Acknowled emenl of Receipt of Materiah <br /> W T Printedj/�T' Name //( Sigrwy/s)� /`y' ( C .;•� Month Day Yeor <br /> I <br /> 0 lei 7` jM 4 <br /> e1I! , <br /> W 19. Discrepancy Indication Space ' <br /> N <br /> V A <br /> Z C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Primed/Typed Nome Sigr .asire Month Day Year <br /> Y r <br /> i <br /> DO NOT WRITE BELOW THIS' INE. <br /> DTSC 8022A (12/91) <br /> EPA 8700--22 <br /> While: TSDF RETAINS <br />