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11/08,12003 09: 19 916-386-4916 SACTO 0-C 760 PAGE 02
<br /> State of CoGFornio—En.;renmenror rroroenon Agoncy —-A ti
<br /> Form Approved OMB No.2050-0039(Expires 9.30-991 Sora Inshuet'on$ on back c ge 6• De oftram of Toxic Substances Contra
<br /> 41 so.print or type. Form designed for use on°Ilre 02-pikh) .triter, P Sacramento,Col;
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<br /> UNIFORM HAZARDOUS I Generator's U5 EPA ID No, Manifest Document No. 2, Pepe t Info1_`_in the shaded areas
<br /> WASTE MANIFEST I""� ��`' I; ,� is not required by Federal lou.,
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<br /> 3. stator's No end Moiling Address la`-c;••=•,l tFes pecu r N
<br /> f+r'I A. Sto"Moro t met+ umber
<br /> 22196564
<br /> Q i- ^.'I' ,w•_rte�� A, Srota Generotat's ID
<br /> vrsl d. Gan rotors Phone
<br /> C14
<br /> S. Tronsporrw 1 Company Name b• US EPA ID Number
<br /> C. store Tronsparfor's ID(Reserved.)
<br /> O -•., _ .. L- D, Tronsporser's Phone -
<br /> Transporter 2 Company Nome mber A. US EPA M Nu
<br /> .- E. State Tronspongr's ID FReserved.l
<br /> VF. Tronsportor s Phone
<br /> ' elgnefed Facility Nome end ro s �; 0, US EPA I Number =a
<br /> ! 1_. ,Sir Address .1 D G. State Foc;lity's Ip
<br /> II'0 �•, J '3....., �r'?L'�r 14r -��s�)��.�." N. Faciliy'e Phone ,
<br /> J U 11, U$DOT Descrlpfion I;nclud;ng Proper Shipping Nome,Ho¢ord Clow,end ID Number) 12- COntalners 13, Total Y 14 Unit
<br /> z ^ No. T Quantity Wt/Vol., I. Waste"amber.
<br /> .lT'O• �, ,r r 51
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<br /> R , EPA/Other ';I; ��y ,
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<br /> U EPA/CNFgr
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<br /> ZJ Adt !iono�Desverrieill V1 d Abo 7' K. Handling Codes For Wastes lasted Above
<br /> F, I_t3 vf�z r".2� r/I D10 �°� b, ,
<br /> ZF ` :\.e L.. .'l k:• I�l,Y,�'LI 7 '•.-,..•. .�'l',..1`'1a� ��\'Idl. '�..,$1 r ., _ -.. :. l'"-, _ �.Uj
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<br /> •J-u I t5, GENEAJITOR'S CERTIFICATION: I hereby declare►hal the ca+renh of This CorsignmeeI oro F,Afy orad oeeureteb desvibed above by proper shipping name and ore classified,pocked.
<br /> lQ! morked,and labelad,oed are;n all respects in proper tondition for Manspor+by h oy according ro applicable Wornotionol and notiono govwrimem regulations.
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<br /> —' IF I omo Jorge quont;y generator.I ceruse that I have o ram in place to reduce the volume and roxlcity of waste generated to the degree I hove def";ned to be eee'nom;col
<br /> practicably and that I hove Wetted the practicable mWhodofen
<br /> wootmt,storage,or dispesol currently avollable to me which minim;zes the present and Futuro throat to human
<br /> fi hum
<br /> and the environrnenl;OR,iF I am a small quantify generator,I have mode o peed foilh effort to minimize my waste penerotion and select the bast wast*monapement method that Is
<br /> O ovaloble to me and rhos I can afford.
<br /> VW'nked d Nome J '`.� .� Si ; Month Do Year
<br /> e17. Trork&oorher I Acknowledgement of Ra"i t of Materials
<br /> LW e Printed/TTyped Name $ignoture`�' / r�' Manch Ise Y*ar
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<br /> 0 0 18, Trans ter 2 Ackno.rled meet of Receipt of Motariols
<br /> TPrfnt�d T Nam* � i Sigraturo Month Day Yaor
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<br /> U F 19. Discrepancy Indication Spoto
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<br /> l20. FociC Owner or Operator Cortification of rata of hozord0us materials covered this m mea except as"fed in Item 19,
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<br /> DO NOT WRITE BELOW THIS UNE.
<br /> DISC 9022A I1/991
<br /> EPA ,zoo-PECEIVED 12-07-' 03 19: 17 FROM- 916 386 4916 TO- CCKW-FRENCH CAMP P02/04=7AINS
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