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SIJD.f of ,nua-. ..jai and Welfare Agency Deµrrment of Heath Se,.. <br /> See Instructions on ba.. of(.9 6. Toxic Substances Control Pr. <br /> Please pont or type. Form designed for use on wife(]2-poteh ty) W. <br /> Sacramento,Cc <br /> Pape 1 <br /> UNIFOJRK4 HAZARDOUS 1.Generator's LIS EPA ID No. Manifest Document No. 2. Infoimaf on k the srx3ded area. <br /> WASTE MANIFEST Of 's not regwred by Federal kow. <br /> 3 Generators Name and Mailin1 .1g Address ` y� A.State Manifest DcK-ument Numbe <br /> - <br /> A. <br /> 10 <br /> a ',? - is State orator's <br /> 4.Gererator's Phone <br /> S.Transporter 1 Company Name 6.US EPA ID Number C.State Transporter s PD <br /> Al lied lE'.0 � ,Ay 11 81U1� 11511 121j D. Transportert:Phone <br /> 7.Tra spartan 0/ <br /> ro ny e 'F 88 US EPA ID Number E.State Trarsporters 1D <br /> 1/ Trc�ns iOrtors Phone <br /> I.Desig sated Efcjc�i`y-Nan g and YpI01(e s� 10.US EPA ID Number G Lr) �p <br /> CN <br /> p <br /> l �5 :, ii,:ii .fJ �$ :"S1)tl H.Facility a Phone <br /> 11.US DOT Description(including Proper Shipping flame.Hazard Clens,and ID Number) 12 Containers 13.Total 14.Unit <br /> No. T Quant M/Vol 1.Waste Numtx,i <br /> J a, cif J V L 1 L1 LL I L44 IJ <br /> state <br />� Q <br /> er __ <br />,jz N Ii ✓ri G <br /> b. <br /> E � <br /> > Q A ( r EPA/C7iriar <br /> a 1 � I 1 <br /> State <br /> R ENVIRONMEN AL HEP <br /> y� <br /> ERMIT/S RViCE I 1 1 1 EPA/Oth©f <br /> N <br /> Mate <br /> v <br /> N x�! <br /> 00 <br /> V I I I I I 1 I <br /> J.Additional Descnpt o s for tvbfer Isfad Abopve K.Ha)yhng Codes fol Wastes Listed Above <br /> Z c. - <br /> w y, <br /> U 15.SpercFiidl fIQt ��74!~ �f�r ��l <br /> cn <br /> z Ur-Slui%ATEO FACILITY �-.iATACT # (40)614-4444 <br /> w <br /> #i htT I ATud EMLRUNCY CUAITA4f I <br /> c <br /> Q 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 classrtki <br /> K. <br /> Oz 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 /> 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 detOrmined to bo <br /> z economical y 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 /> LU threat to human health and the environment;OR,A I am a small quantity generator.I have made a good lath effort to minimize <br /> my waste generation and select the best waste <br /> � management method that is available to me and toot I can afford. <br /> J <br /> -' Printod/Typed Marne <br /> Q S gnature <br /> Month Day ar <br /> U <br /> a < I ..� j • il ' I rt <br /> C T 11.Transporter 1 Acknowledgement of Receipt of Materials - <br /> 0 R Pnnted/Typed Marne <br /> Y A Sjynature Month any ye,u <br /> P114 r ir. is' 'Ot'jt ;.f r;,. <br /> Lv O 18.Transporter 2 Acknowiedgement of Receipt of Materials - <br /> w R P nted/Typed Na <br /> T Signature Month Day year --, <br /> ra R C� < `I l <br /> mob'' �,� <br /> Q19.Discrepancy Indication Space <br /> U FIV <br /> Z A W� <br /> C <br /> L20.Faalrt Owner O <br /> I Y or Aerator Certification of receipt of hazardous materials covered by this rnanrfest except as noted in item 19. <br /> T Printed/Typed Nam; Signature <br /> Y Month <br /> GUy yaor <br /> DO NOT WRITE BELOW THIS LINE. <br /> DHS82/90) <br /> EPA Green: HAULER RET <br /> EPA 8700-2700-2 2 <br />