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Stare;f Ca6fornic—Envin.min of Protection Agency <br /> Farm Approved OMB No.2050-0039(E.plrc.930-94) See Instructions On back of page 6. Depar,mem a1 Ta.ic Subs,moo Co.,, <br /> Please prim or type. Form designed for use on elite(12pirch)typewriter. Sacramento,Calif.,.. <br /> UNIFORM HAZARDOUS 1, Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not recI by Federal law. <br /> WASTE MANIFEST <br /> 3. Generator's Name and Moiling Address A tateeMnnffumba'<" <br /> Realst� <br /> � �J <br /> �(J �s <br /> t. �f �d"/�� _i '•Fk GeRe*atoh ID As p $ r <br /> 4. Generator's Phone ( j /a `'�'/ g� J� 1 <br /> p 5. Transporter I Company Name 6. US EPA ID Number <br /> O <br /> 7. Transporter 2 Company Name <br /> V S. US EPA ID Number 'E- tate ni�oitel'-D ' w <br /> St <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number G talc IiIj7VDr .} <br /> Z Coed L, <br /> —1 4Q ,o �s�7i� ! $ K: O aZ7 70�� r: <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Comoiners 13. Total 14 Unit <br /> �— No. Type Ouanhty wt/Vol 1 Waste Nu bet <br /> 1=- a• ///��� 5 xOJ(p Sod/D State <br /> 3 <br /> 0E /�lEPA <br /> C N 6n7/�07a2L�?l66I/a�T� <br /> O <br /> 00 T °' State <br /> m O <br /> R FPA/Ohher <br /> d. gate <br /> Z <br /> J <br /> w EPA/Other e <br /> N _ <br /> Z «4ddewrwY - K. Handling Cod cs for Wastes Listed Above <br /> � F t ,*r� <br /> Q 15. Spedol Handling Instructions andAddition Inlorma�o2. <br /> 16, GENERATOR'S CERTIFICATION: I hereby declare that Ine 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,Hare and international laws. <br /> U <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 1 have determined to be <br /> Jeconomically practicable and that I have selected the practicable method of he menp storage,or disposal currently available to me which minimizes the present and future <br /> Nthreat ro human heahh a d Me environment;OR, if I am o small quan8ly gene tor, have made a good faith effort to minimize my wove generation and select the best <br /> wast m na ement metho that is available to me and that I con afford. <br /> Q <br /> Prior ye Nam99 v Signature .c `., Month Day Year <br /> Z T 17. Tram over I Acknowledgement of Receipt of Materials / - <br /> w e p�. . . <br /> Ur A `� //Typed Name Signor / Month DoY`/ <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> w r Printed/Typed Name Signature Month Dap Year <br /> LL <br /> O e I <br /> w 19. Disuepancy Indication Space <br /> N <br /> Q F <br /> V A <br /> Z C <br /> I <br /> l <br /> I20. Fbcili Owner or Operator Certifimtion of receipt of hazardous materials corer anifest exce t as noted m Item 19. <br /> T Primed/typed Name Si �- Month Day Year <br /> 5 I V F ! Iyl <br /> DO WRITE LINE. <br /> DISC 8022A (7/921 <br /> EPA 8700--22 <br />