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State of Can rnia-Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) <br /> Please print or e'°Fbrnl designed for use on elite 12• itch See Instructions OD back Of Page 6. Department of Toxic Substances Control <br /> P y�P 9 <br /> (12-pitch)typewriter. , <br /> 1. Generator's US EPA ID No. Sacramento,California <br /> UNIFORM HAZARDOUS Manifest Document No. 2. gebT `nFormation in the shaded areas <br /> WASTE MANIFEST = - <br /> N F J t is not required by Federal law. <br /> T3.,,Geneftprs Npgre o �M <br /> 4L <br /> A. <br /> QddFeFs � L � ~ of <br /> .4L; <br /> -ii._ •_ T` w,�1-?�'! s:`.:;� r �., A. State Manifest Document Number �y <br /> q.r-2pt 2."'4A ,.l v1�?t: .�C 5T ?i.�Pd V <br /> td�sln]G t+iY'6t '?tT Are�C ,�'e <br /> sh, . <br /> 4. Generator's Phone(�41 T'� � '� v 8. Sta a Generator's ID <br /> I Iry 'i i ATr?N; ��t(3ra '' rf { s-1 <br /> v s ? <br /> CV 5. Trans ort r 1 Co pq f EPA ID Number <br /> m j s ;• T{✓K. , .t!1 ff J£�:i _'rs 1 C C. State Transporter's ID[Reserved.] <br /> O I _ - <br /> ✓/la i Z/��f �j 1 1 )�, + UX:- <br /> 2 A D. Transportei s Phone i ! r <br /> ou O D O 7 feGG'M1Aa <br /> 7. Transporter 2 Company Name 8. A ID Number <br /> E. State Transporters ID[Reserved.] <br /> JJ <br /> Q F. Transporter's Phone <br /> *111U 9. Designated Facility Name and 5ife Address <br /> 10. US EPA ID Number G. State aci i 's I <br /> .35,k31 JLC ZK' J1 E`0AC7 <br /> 0 Z+TIf•„�{�jIA<N CJ1T „',:j.'323f9+ - r H. Facility's Phone <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers <br /> 13. Total au —FA. Unit <br /> Z a -'. C .�.A,.+ .a _%t,V M ? Vi t v,Jt�I�r 1: No. Type Quantity Wt/Vol I. Waste Number <br /> T <br /> 2 „ ' <br /> :ro t H TPAC 41ETA LE /� /� p State R4#. <br /> T 000 0 14..$ df"t.�.� <br /> 0 <br /> NE b. <br /> `p E stare <br /> R <br /> v A EPAOC. <br /> ther <br /> T <br /> n OState <br /> R I <br /> ! <br /> ti EPA/Other <br /> Ll d. <br /> State <br /> J c <br /> 'U ^~1. EPA/Other <br /> r a <br /> L Additional Descriptions fi i Mat rials Listed Above L <br /> 7 1 K. Handling Codes for Wastes Listed Above <br /> �tRl1li_L�t`�]�rsl[ `si ,+ <br /> w s r �'e,X17'i'11'�,�t'w,�'�rt1�'#'�L�u?F~[�Fds-11�7; (J <br /> T <br /> j 15. s�« U+g�l� Suctip�an d Cl I far gt y <br /> - f � 'n 'ttOP6aL4, HR <br /> ,�� Q r.: i•�?,*'.d Rhihp Trans Rs'�..ern--4j1..tirr ri�31.. 2? );f <br /> 0 1 <br /> f <br /> 1 b. GENE$/1TOR�RTIFICATION: I hereby declare that the contents of this consignment are Fvlly and accurately described above by proper shipping name and ore classified,packed, <br /> ` marked,an abeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> ,t <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxiciy of waste generated to the degree I have determined to be economically <br /> 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 /> K and the environment;OR,iF I am a small quantity generator,I have made a good faith effort to mini' my w este generation and select the best waste management method that is <br /> available tome and that I can afford. f <br /> r ] 1 <br /> r Printed(7voe.A 1J+pye�_ Signat - M n7 ' Day, Year <br /> T anspo iC 1 1 e r <br /> R 17. Trans orter 1 P,cknowled ement of Recei t.of Materials <br /> A Printed/TypecLName % j - "'•A <br /> < N �l � I Signature !' Month Day <br /> a Year <br /> P '\ - / ' y. <br /> y, I y J , <br /> u 0 18. irons orter 2 Acknowiecl ement of Recei t of Materials {� <br /> R Printed/Typed N me t <br /> E Signature <br /> R Month Day 'Year <br /> ^I <br /> F 19. Discrepancy Indication Space I <br /> IA <br /> C , <br /> I <br /> I � f <br /> f 20. Facility Owner or O erator Certification aFwecei t of hazardous materials covered by this manifest exce t a `oted in Item 19.------------------ <br /> 1 <br /> T Printed/Typed Name <br /> Y .f� Signature <br /> -_ Month pay Year <br /> DO NOT WRITE BELOW THIS LINE. / <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> )TSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> 8700-22 produce completed copy Of this copy and send to DTSC within 30.days.) <br />