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State of California—Environm{tf it Protection Agency i j <br /> Form Approved OMB No.20, -00,39(Expires 9-30-99) See i-Aitctions on back of page 6. <br /> lease print or type- For at j ger]fgr usaon elite 112-pitch)typewriter. Department of Toxic Substances Control <br /> t', _go' e <br /> � Sacramento,California <br /> UNIFORIN AZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST is not required by Federal law. <br /> A F -5 ^ ? of 1 <br /> 3.pen yLgrts f�mSpndd�M��ili¢g q� r A. State Manifest Document Number <br /> ;�t tC aJA'Z"r"�1M.Iff�'��t�i� t)r <br /> 77 9eale Street E 24A UN00jE 74%^°'O. is i MILE y�%'EST+.`.,f+,';.,..IVKP-: 20255384 <br /> Oa San`rat-ate CA 9A105. j_�?�4+�f= "A-95330 - B. State Generator's ID <br /> LO 4. Generator's Phone 14 j 5 ) -973%3773 GraRj <br /> y <br /> C14 5. Transporter I Company Name /�' fjPA- DNutnk_4r , A 4( ;r6 C. State Transporter's ID(Reserved.] <br /> 00 <br /> 0C4.1 '�lrlJ�ayg. _ - - 9`TLv`fIe1 s , r <br /> c? 7. Transporter 2 Com an Nome r- <br /> P P Y 8. US EPA ID Number E. State Transporters ID[Reserved.]' <br /> �J <br /> MJ <br /> W Q F. Transporter's Phone <br /> M V 9. Designated Facility Name and Site'Address 10. US EPA ID Number G. Stat ci• 's 1 <br /> LnZ HEMI AL Ig�,�,STE`1ANAGEIJE: IT lel: 41 <br /> OX) ' L -t <br /> • k- H. Facility's Phone <br /> NjTO � si^ 9F9329 _ 14 r 1 j� 14 <br /> pp 'rYSC223p4 <br /> Q 11. US DOT Description mcludin Proper Shipping Name,Hazard Class,and ID Number 12. Containers 13. Total 14. Unit <br /> V P ( 9 P PP 9 ) No. Type Quantity Wt/Vol L Waste Number <br /> ' Z a.IUt9f4 f�3vr� 'r: ✓>� b `�!a_;'�UL'{ f-:=1 �.1 v t�f!(Ir3 U <br /> $tate ,{''. , <br /> ACE WrALS'l <br /> 3 c _ <br /> i� Fill <br /> EP,qq <br /> E <br /> C) N b. s►a !m .= <br /> �r.. , <br /> ao E <br /> N R e EPA(Other K'n ``i <br /> o T ` <br /> co O <br /> Rall <br /> Lu d. <br /> Z skt t P <br /> uJ <br /> U <br /> Z 7 Zdddiidwons Descriptifor aterials Listed AboveK Handling Codes forpstes Listeb2 F+ it Ol1ti3Lid:I3. €#3�f fifi�! EA# t 177,4 - 't <br /> Y <br /> Q ^" :3 yi Medy <br /> Q 15.E pedal Hog Instructions and Addi Tonal Information <br /> e ar ff�r gogges as apprssprajes4 alt, r_0ntart a - _ee '3aarm5- P-Ii ir, T-ns R'aeMed;Rtic- -1-S03-321-1030 <br /> Z t` : E 1�3�. ;ra�f? i Y0#: 33M, Tram 2 P <br /> Lu <br /> Q16. GENERATOR'S CERTIFICATION:n aI hereby declare that the costter]ts of this consignment are fully and accurate]y described above by proper shipping name and are classified,pocked, <br /> U marked,and labeled,and are ill respects in proper condition for transport by highway according to applicable international and notional government regulations. <br /> J .'f <br /> 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 /> N 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 /> 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 /> O available to me and that I can afford. <br /> V Prin��gqd/kyjpq� PAY Sign6fur ( Mont Day Year <br /> "s OT3Pi E i <br /> Z d <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> C7 R <br /> Lu <br /> Prin a /Typed Na ,q /,� Signa r Month, r Day <br /> rear <br /> SV4oc4u� y <br /> P <br /> u- 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 R Printed/Typed ed Name <br /> w E YP Signature Month Day Year <br /> N R <br /> Q <br /> U F 19. Discrepancy Indication Space <br /> Z A <br /> C <br /> I <br /> L <br /> 20. Facility Owner-,Operator Ce ification of receipt of hazardous materials covered by this manifest exceiroasknoted in IMm 19. <br /> T Printed/Typed Name Signature <br /> V Month Day + Y a <br /> .6 <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />