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State of California—Environmental Protection Agency - <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back Of —nge 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch niter. i ,4 .) Sacramento,California <br /> t UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> „ is not required by Federal law. <br /> j WASTE MANIFEST of <br /> psr is Name_and Mailing Address "' "-.i <br /> 3! ' A. State Manifest Document Number <br /> 22519032,. .. 2519032: <br /> ' n� ,:? ' -r"'' B. State Generator's ID <br /> LO <br /> 4. Generator's Phone <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> W') <br /> ao c:: r.. <br /> f_. V f 'v j l !,:. ! D. Transporter's Phone <br /> 0 900 66re -15 r <br /> ao 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> rV� <br /> ,•/Q F. Transporter's Phone <br /> V 9,�s npt@d Facilitypr pn�,$ite Addyss� �' ^' 10. US EPA ID Number G. State Facili s ID <br /> Q r 1 t { _a:l` r E"•iii 1.�t L-3':`s: T}�! f.r� u 'sF;'7..4 7 .'� <br /> TH <br /> �Ce ._: -iM1']X ,.TTCi CA 95C4c,'i"'I ;.`.r`,: . �'y�.i.(�; I H Facility's Phone <br /> AD 0 <br /> 12. Containers 13. Total 14. Unit <br /> eV V 11. U$DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> Z a State <br /> 3s rte' DOC I tO1 s L. " 1 !ys ��— EPA 01h <br /> N E b - t- n _ State <br /> O N s I i [..' i eat c i r,F L 1 ? <br /> a0°o E f r X = SRC`#12 ? r # ':r�1 s L 1 s'.J; ij=7:.i !`t0 <br /> f r 1 �, [` <br /> R 711EPA/Other <br /> V A c State <br /> o T <br /> 000 O <br /> R EPA/Other <br /> LU d. State <br /> Z <br /> w <br /> V EPA/Other <br /> W <br /> y A4iflonatDasgq ons ttlp rials Liste� K. Handling Codes for Wastes Listed Above <br /> Z i ict1 ul+ '..> s.rlt{E2$ =t. ���13y3 6 {�:Bt�'0'�? t?Q <br /> 1 ? 1-. `,% 1iaSf}i f D,-,18r 00•.. !,z,,.)r FCy a Litt 91 D040 a. z b' 14 <br /> W r <br /> oc ! C. d. <br /> Q 0 , <br /> Z15 Special.HandlingJnstrLctiona,gnd Add Cignal Jnformahon. <br /> ZtN _.. . _, _]`�.rS. �._ E4DLij Cy:, r,{^'i? .! 1-' CAE f.;���� <br /> LLI '4 <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the coRrents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Umarked,and labeled,and are in all respects in proper condition for tronsport by highway according to applicable international,nationol government regulations. <br /> ? ; <br /> J f f - <br /> -' If am o large quantity generator,I certify that 1 have a ograth in pl cq't6�reduce the volume and toxicity of waste generate to the degree I have determined to be economically <br /> d practicable and that I have selected the practicable me o tr►aljnenl, orage,os�iposal currently available to me which minimizes the present and future threat to human health <br /> H and the environment;OR,if I am a small quantity gena r„.I have made o good ifalth effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I con afford. <br /> O <br /> >. DMine D <br /> Month- Days Year_J <br /> V <br /> Z <br /> I �wb <br /> u t T 17. Transporter 1 Acknowledgement of Receipt of Materials =- ' <br /> C7 R <br /> Cie A Printed/Typed f4ome l SiVbture �` --` Month J]p�y­ Year 7 <br /> LU <br /> Wp 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printed/Typed Name Signature Month Day Year <br /> w E <br /> N - <br /> Q <br /> V 19. Discrepancy Indication Space <br /> Z f <br /> A - <br /> C <br /> I <br /> L <br /> l 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 <br />