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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on backof age 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite f 12-pilc writer. Sacramento,California <br /> UNIFORM HAZARDOUS enerator's US EPA ID No. Manifest Document 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST " (/�� r!J a not required by Federal law. <br /> of <br /> 3. Generator's Name and Mailing Address t ( m 1 A. State Manifest Document Number s <br /> 21 <br /> O B. State Generator's ID <br /> h n <br /> 4. Generator's Phone <br /> aY-a1! + " <br /> ry „ X j <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> CP <br /> O t*?.; <t.1`hf`< .:�,.:..i.t.:� 'xs'l4`g; C.. t.11 f''k L6,;+ ?J t.lt is" Ci D. Transporter's Phone _s3,.J <br /> O <br /> 09 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> F. Transporter's Phone <br /> V f94,LbI�P,,e 4n�. �fe� s <br /> Q ,J�e4i9[�aced I' S d.,dfe55a � 10. US EPA ID Number G. Stat?fac�tity}ID, <br /> It, 1 <br /> . H Facility's Phone <br /> ' 2i <br /> J C . J q a # . $ <br /> 11. US DCN Description(including Proper Shipping Nome,Hazard Class,and ID Number 12. Containers 13. Total 14. Unit <br /> Q P l 9 P PP g I <br /> U No, Type Quantity W!/Vo! I. Waste Number <br /> Z a. State <br /> 3 G ? 4,fP�. t t}f 1 i, f EPA/Other <br /> O N b' State <br /> co E <br /> R EPA/Other <br /> v A <br /> C. <br /> o T State <br /> co O <br /> R EPA/Other <br /> w d. State <br /> t— <br /> Z <br /> w <br /> U EPA/Other <br /> w <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z ..,- <br /> 0 Oli_Y WA ro f E:.#i° <br /> w <br /> C. d. <br /> Q <br /> 0 15. Special Handling Instructions and Additional Information <br /> t— <br /> Z �yy 1: `t(v pp liP tp <br /> U ,-.eb�l:P" ENr.�Y Gg 9`P L..� ^lis aJC1`9_f3(; •!'. 857 <br /> = j <br /> F-- <br /> 16. GENERATOR'5 CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described 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 government regulations. <br /> I <br /> J' if I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and that I can afford. <br /> O <br /> } Printed/Typed Name p Signature / y_. ( i_' Month Day Year <br /> ZI ✓ J�J t. -Tl/gr 4�s•�r`LIv.L/�,. ,^"'y .GI .®'°'^•'. l �- r." <br /> LU 1 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> � R <br /> w A Printed/Typed Nome Signature ;!` Month Day Year <br /> w 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> O R Printed/Typed Name Signature Month Day Year <br /> w E <br /> N R <br /> Q <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I I <br /> L <br /> 20. Facility Owner or Operator Certificotion-of receipt of hazardous materials covered lay this manifest exce t as noted in Item 19. <br /> T Printed/Typed Na'me� / -/", Signature / ,,� A Month Day Year <br /> r ' <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) <br /> EPA 8700-22 " <br />