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St to of California Environmental Protection Agency '
<br /> For roved OMB No.2050-0039(Expires 9-30-99) See Instructions on back 6f page 6. Department of Toxic Substances Control
<br /> Please p—nW§z9r type. Form designed For use mn eke
<br /> 4l i�;pitchl typewriter. Sacramento,California
<br /> UNIFORM HAZARDOUS
<br /> 1. 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 /> WASTE MANIFEST i; of
<br /> 3 Ge eccciter s Name-c J�loilis Addae»,;; �- z r . A. State Manifest Document Number
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<br /> N 5. �gGsport r 1 tr ny Name 6. US EPA ID Number" C. State Transporter's ID Reserved. -
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<br /> O '� '� `3 - 'i D. Transporter's Phone v'-. .t 7?
<br /> 07 7. Transporter 2 Company Name 8, US EPA ID Number E. State Transporter's ID[Reserved_]
<br /> +J F. Transporter's Phone
<br /> MU 9 Designated Facility Name and Site Address 10. US EPA ID Number G. S ate,act t D ( 40n
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<br /> 12. Containers 13. Total 14. Unit
<br /> �U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) __ No. Type Quantity" Wt/Vol I::Waste Number,
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<br /> J. Ad ''anal Descriptions for Mate ngs Listed Above K. Handlingast
<br /> Cod for Wes Listed Above
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<br /> sn m1 -fF*N-? *l-fFv O ED V1ITH T kC. METALS C- kZ'1771;
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<br /> 16. GENERATOR'S CERTIEICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed,
<br /> U marked,and r�ed,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> J If l am a large quantity generator,I certify that I hove 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 1 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 ray waste generation and select the best waste management method that is
<br /> O available to me and that I can afford.
<br /> ZPrinik6&rp!N me Signat6re g v'M- nth Day a Yea
<br /> 0 TR 17. Transporter,l Acknowledgement of Receipt of Materials
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<br /> A Printed/Typed tJame j) Signgture � Month Day Year
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<br /> P \r
<br /> ti p 1 8. Transporter 2 Am
<br /> cknowled eent of Recei t of Materials
<br /> OT Printed/Typed Name Signature Month Day Year
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<br /> U 19. Discrepancy Indication Space
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<br /> 20. Facility Owner br O erator Certification of,—receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name j� h; r r i7Signature , Mon(Tt J Ddy: IYehr
<br /> Y .:`t E `ltP r g 7 it �. f r
<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 /> 417--71)0 4-
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