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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 -,ge 6. Department of Toxic Substances Contrc <br /> Please print or type. Form designed for use on elite(12-pitch) 'iter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST ('t jj is not required by Federal law.of ! <br /> 3. Generator's Name and Mailing Address v A. State Monifest Document Number A <br /> 991 <br /> O B. State Generator's ID <br /> h <br /> A. Generator's Phone ( Iz:110 <br /> -7 i <br /> CV 5. Transporter 1 Company Name ' 6. US EPA ID Number C. State Transporter's ID(Reserved.] <br /> LO <br /> ao <br /> O D. Transporter's Phone <br /> 7, Transporter 2 CompanMt. 8. US EPA ID Number E. State Transporter's ID`(Tteserveif�4 <br /> QF. Transporter',Phone <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> a. - - -,t, ,-0 H. Facility's Phone <br /> L r r t 12. Containers 13. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Nome,Hazard Class,and ID Number) <br /> U No. Type Quantity Wt/vol I. Waste Number <br /> Z a. State <br /> 134 <br /> _ rSCti?YlE�a�t',11ira <br /> 3 G i�y`•.&_'. S.'T. T n n 1 � EPA/Other <br /> E -r _Y / D !t - ! , - _ <br /> ON b. `. __...___ _.., . -...-.. ,..._ State <br /> 00 <br /> 00 E <br /> R EPA/Other <br /> A c State <br /> o T <br /> aa0 O <br /> R EPA/Other <br /> LU I d State <br /> F <br /> Z <br /> U-1 <br /> U EPA/Other <br /> LU <br /> h J. Additional Descriptions for Materials Listed Above 11 K. Handling Codes for Wastes Listed Above <br /> Z } <br /> o. b. <br /> "X0 Ncrffi 62T1t?Y'L1:an ElvEIRaERCY PXSP014SE i UM—E-X,731. 128 <br /> LU <br /> ne L.L''R Nwficatim statm t is nct required avljarmwy, 99(5 C. d. <br /> a HSC Citaticn 25179.6 <br /> Z <br /> 0 15. Special Handling Instructions and Additional Information <br /> Q .. <br /> 3St�[iYiF and'.'`3Lf�r mist . Weir 1;"i4ppi-q'i iaL pr�t.^�'''mve s_i0►`k14. P.�cc, A912 ERR#C�8 3y <br /> Z <br /> 16 East Hffi duv,tx�ay <br /> LU r�-S� <br /> Olt-, n c -SSTt�t..[Y.�f�?i 'A <br /> !; ,[� - 3'I arr,t 3.,OYYi) <br /> 16. GENERATOR'S name and are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and nationaS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> government regulations. <br /> U <br /> If I am 0 large qu0ntiy generator,I certify that I have a pr ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method <br /> yam <br /> storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort 1 'ze my waste generation and select the best waste management method that is <br /> available to me and that I can afford. j <br /> Printed/Typed Name Signature / ^Aontf� Doy �YeaF <br /> Z `_!$1t of fi4Rr'.�1 /!! ;' � A: <br /> Z5T w R 17. Transporter 1 Acknowledgement of Rech t of Ma erials <br /> LU A Printed/Typed'PTa- ,7 !1 jonth 1 Signature <" ----`' ,.Day Year - <br /> R <br /> W <br /> s+- 0 18. Transporter 2 Acknowled°ement of Receipt of Materials ' <br /> Month Day Year <br /> T Printed/ Typed Name Signature <br /> w E <br /> Q R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> 1 <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> 7' Printed/Typed Name Signoture 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 />