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State of California—Environmental Protection Agency ... .
<br /> Form Approved OMB No.2050-0039(Expires 9-30.99) See InstruCtlOns on back Of Dage b. Deportment of Toxic Substances Control
<br /> Please print or type. Form designed for use on elite(12-pitch vriter. ys % Sacramento,California
<br /> •.+ venerator's US EPA ID No. Manifest Document I._ 2 Page 1 Information in the shaded areas
<br /> UNIFORM HAZARDOUS - is not required by Federal law.
<br /> WASTE MANIFEST41b I of ..
<br /> `3. GeneratZ/�i Name and Mailing Address — — I`," - "'t-•s + A. State Manifest Document Number
<br /> 228739231 ;
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<br /> O " f'` �.�rhr�l re +•,;+^t t^+�'`._ ._ - _1i, B. State Generator's ID
<br /> Lr) 4. Generator's Phone( ZP`?) {-4;3 69'.
<br /> N 5. Transporter 1 Company Nome 6. US EPA ID Number C. State Transporter's ID(Reserved.]
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<br /> 1"� �'("�l+I •..tY:: f :.a'L..,, tr ,�� 7. .. ✓',. ` /_:.•,.` D. Transporter's Phone
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<br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved]
<br /> F. Transporter's Phone
<br /> U9. Designated Facil'tyAl ndS't
<br /> Addr10. US EPA ID Number G. State Facility's ID
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<br /> oc r{f f[i CA ,.l..r12F,`i �rr4, .. F11.;�:r1.a',:% H. Facility's Phone
<br /> U Q12. Containers 13. Total �14. Unit
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<br /> U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Yo) I. Waste Number
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<br /> v7 1 Ad itiona`Dkt{{)tlpns�pG triols Listeyi Abovg K. Handling Codes for Wastes Listed Above
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<br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment•Cre'Full nd accurately desefibed above by proper shipping name and are classified,packed,
<br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national 9oyernment regulations.
<br /> If I am a large quontily generator,I certify that I have a program in place to re a volume and'toki6 y of waste genie cted to the degree I have determined to be economically
<br /> practicable and that I hove selected the practicable method of tredtm e ' r posal currently-ovailabfe tome which minimizes the present and future threat to human health
<br /> and the environment;OR,if I am a small quantity generator,I;4r, netait effort to minioze my waste generation and select the best waste management method that is
<br /> available to me and that I con afford. "t
<br /> P' e T ome Si n to •A Mond Day Year
<br /> Z i t-� t 1 Ltb� '� F ` � j
<br /> wo 11
<br /> T 177tronsiaorter 1 Acknowled amen!of Recei t of Materials
<br /> R Printed/Typed!Came ( Signature r,,,:� "> �'' ~• onl� y� Year
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<br /> u_ 0 18. Transporter 2 Acknowledgement of Recei t of Materials `
<br /> 1 Printed/Typed Name Signature Month Day Year
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<br /> V19. Discrepancy Indication Space
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<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 Printed/Typed Name Signature Month Day Year
<br /> Y
<br /> DO NOT WRITE BELOW THIS LINE.
<br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS
<br /> EPA 8700-22
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