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Slate of Califernio—Endrenmemal Protection Agency <br /> 1 in Approved OMB Ni,.2030-0039(Eapina 9JP94) See Instrvatons on back OFa e 6. <br /> P 9 Depanmem of rewk Substances Cmsuil printty <br /> or pe. Form designed For use ons eliH(/2piKh)typewriter, re California <br /> I it UNIFORM HAZARDOUS I. Generator's US EPA ID No. Manifest Document No. 2 Poge 1 Information in the shaded areas <br /> WASTE MANIFEST s non regaued by Federal lay.. <br /> C/� i � z l 9 3 G C i <br /> 3. Generator's Name and Mailing Address <br /> C t f- <br /> � <br /> IN d. Generator's Phone QC9 /CJ o 3e1t - 1 <br /> 6O' 3. Transporter 1 Company Name l6. US EPA ID Number <br /> O(Q-NR� <br /> -' ' ` 5"-krCL lC! `U Tran`"rlers' <br /> $ 100 <br /> J 7. Transporter 2 Company Name B. US EPA ID Number £ASSlalo "" p <br /> U <br /> ra 9. De' aced Facilit�{Nme and Site Address 10. US EPA ID Number xC>v°,ta[e "'Gly/;D <br /> .:W �+� Y Zr! <br /> iurce- 6Y <br /> .�L� Vl-• plwlte rr <br /> %� (� 9LI-110 /�0 G 3 �' ,.x, n kc-0 <br /> 12. Containers 13. Total la. Un0 <br /> Z 11. US DOT Description including Proper Shipping Name,Hazard Class,and ID Number) N--o. T Ouantiy WI/Vol •.:},_o9e <br /> 3 a. b�c.Zc�fclok.s 1.c1«5}e SJI�a IsntS C5.1 Je-J � � y'` <br /> E I Ods t -r✓ N(1�t1$� l . � �. <br /> E b i- tLZJ-f(fta-L5 W"Sk Se,Lo ICS LSi <br /> A SRP t-C IJ18`i M el 0.2ji IS � . <br /> 0 T c. ..^- <br /> co D _ <br /> R :FPA 011ier. <br /> w <br /> Z d. <br /> ILI <br /> •s <br /> U A fie`i <br /> N 1 <br /> Z <br /> ° 1'ane;of <br /> T.o`�c' 'W'Wastes^iisrNf3sEo'e <br /> w <br /> Z <br /> O 15. Special Handling Instructions and Additional Information <br /> z G-10�� G 4Ci <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment am fully and accurately described above by proper shipping name and are classified. <br /> Qpacked,marked,and labeled,and are in all respech in proper condition for transport by highway according to applicable federal,state and internotionol laws. <br /> V <br /> If I oro a large quantity gaurat.,. I certify that I have a program in place to reduce the volume and tonicity of waste generoted to the degree I have determined to be <br /> —r ecorwmicolly 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 /> ydj threat to human health and the environment;OR, if I am a small quantity gen tor, I have made a good faith effort to minimize my waste generation and select the best <br /> rite management method that is available to me and that I can afford. <br /> O Printed/T d Nome Sigrwmre Monte Day Year <br /> U O o <br /> Y 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W e <br /> Vr 5 Primed/ ed ante)• r Si@nature�A ^�11 onS ` D172 1 year <br /> Kill <br /> � U r 1 � f. 3 <br /> w r <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> w T Printed/Typed Name Signature Month Doy Year <br /> a- <br /> e <br /> 0 e <br /> w 19. Discrepancy Indication Space <br /> N <br /> Q F <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 m mfest except o noted in Item 19 <br /> T Printed/Typed Name SigoawmMonth Day Year <br /> Y <br /> 0,9,c- -� n`o;2� 1J 3 1 q 3 19 3j <br /> DO NOT W T BELO T IS LINE. <br /> DTSC BORA 17/971 <br />