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12/08/2003 09:19 916-386-4916 SACTO 0—C 760 PAGE 03
<br /> Farm,ApprovedOMBNo.2050-0039'( rehV"699i ' , �'�' ` See on back - ' -age 6. D r;meetpFToxre`
<br /> Exp' apo Subsronces Conlr
<br /> a;plvo}e print or hype, Form designed(or use on e1Pre(12•p4c, .riper Saeromenro,CollFornl°
<br /> INV"
<br /> 1, Creneraher's US EDA ID No. Manifest Document No. 2. poly 1 Information In 14 el+oded areas
<br /> UNIFORM HAZARDOUS CA;,,`;�y t c6.:;1`-.� :'? is not required by Federal Jew.
<br /> • WASTE MANIFEST of '
<br /> yrserq�ors,Nome-and Mo;jing Address t r.'a I" t + s v nr.:�t I h� A Srob MonhFeff DeeumelH Number
<br /> ! stare Generoror's ID e4 irr+
<br /> h 4 Generator's Phone
<br /> N 5. Trons Orta Com an 1 .:r.: w •, -
<br /> p p y Name
<br /> 6. US EPA ID Number C 57me TmnsQorle/s ID( ] ;
<br /> ...`'��TL:i-i�:ir ii�Il., ? .., . .. . �� ,u r + �,�..�Aq►:.
<br /> }' d;??{?OcF��i9;��' D T.ompartersPhons
<br /> r)a' 7. Transporter 2 Com Name ' -.N, ,.•
<br /> spa pony A. US EPA ID Number E $tote Tro�+spoMer't ID Reeetved I
<br /> k�,.. ,.rJ V R,..Def; netldFOeili µ� pndSroAddt�
<br /> rt '7 prJ 10. US EPA 10 Number G rS'lale F,�il�D/l �Pt, ,� 1* s"•mon ��� .
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<br /> CA -4592t . 5 17 N fxtlpl�s Phone
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<br /> 4 12. Conpoiners 13, Toto, 11, Untr " +U 11. US DOT Da.c.iprton pnduding Proper Sh;ppletg Nome,H°tord Coss,and ID Number)' •,•'L,. � V,,'y�'�•,
<br /> Z No. T Ckmml VA/Vel D�1►Number
<br /> RG UASETE F`t:ENT PEL.%TEK Ht rEVIA1..
<br /> F003;- T31 18, D0135
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<br /> ?1z 1-r ep {- yfW� 0h1yyMR��/�e�,�� 1 at!� T ,� .ly rL`'�v\\� t mQ�adeA Wastes�111ed y ry
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<br /> 0 '1,Sf,Special Mothdllap.lnit�yd'ans9rtd�adl lianol,lnforMo►o� J, �••' , fa.,_ .•f-, s% •J + 'J .7 i:.1 l,n_
<br /> - �_ L_ 65`24�"�F" -..-}i.
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<br /> Q16. GENERATOR'S CMITICATION: I hereby declare that the contents of this cwilg nment are W, and oceurotel deser;bed oboes 6y proper of Ing none and are closs;Red,poc4sd,
<br /> V marked,and labeled,and are in all rospens in proper condlHon for transport by 111111 ey bete, ;no to applicable Imernotional Dod zionol govern"Mp regulaH°til,
<br /> If I am o IoVe quentl generoror,I Certify Ihot I hese a"pro�ram;n pksce 10 troduoe Ihs'rolome and toxici OF welts L I Ia ee
<br /> CLI z { ly g�e.nervrod to rte degree I have determined to be ecenoTieollrr
<br /> V) praetkoble and Ihw 1 are selected the praet;cobfe method a Ireemtenr ,,Drape,or ditgesal currently ovailable to me w hieh minimizer the present and Future threat to humor heallfi
<br /> at and the env;ranment,OR,if I am a small gxAtity generator,I have mode o good kith.eflart to min;mite my waste genewl"and Ieleet the best waste management method tl+ot is
<br /> 0 available to me and shot I can oF6rd. J
<br /> z S•9 *v x) on Year
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<br /> 0 T 17. Trons star 1 Acknewle mens of Rocei p of Materials r.....,.....,..
<br /> W I Orin MO/Typed Name .:
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<br /> %r � y�
<br /> -
<br /> IJ_ 0 19, Trans
<br /> portor 2 acknowled emenl of Receipt of MoMriols
<br /> 0 A Printed/Typed Name Signature " * Month !VDoy Year
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<br /> V F 19. Discrepancy Ind;co+;on Spocn n
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<br /> ( 20, Facility Owner or Operator Cartificotlan ai receipt of hazardous motor;asst vexed b f fhismtan;fest e t as rated In Item 19:-
<br /> T ;Tatted/y ped Name SlOtsoture N . I
<br /> h i t�ti r % Year
<br /> 71
<br /> D NOT ITE BE T IS UNE.
<br /> OTSC B022A 11/99( v
<br /> EPA 87OPECEIVED 12-07-'03 19; 17 FROM- 926 386 4916 TO- CCKW-FRENCH CAMP PW' 4RETAINS
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