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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) S@@ Instructions OA back Of Pd9@ b. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch]typewriter. " Sacramento,California <br /> 1. Generators US EPA ID No. Manifest Document No. - 2. Po eyl Information in the shaded areas <br /> UNIFORM HAZARDOUS g <br /> is not required by Federal law. <br /> WASTE MANIFEST _ -0 IQ :T w 3 F € _ f. of <br /> 3. enera r N A "and M ili a r s . <br /> . {Q A,9 ��S,i A. State Manifest Document Number <br /> ''1`3 R�y!'dLqr�S.Ct_.s riti.•`. �_ iA 7HR X1,"'7`-..I"r..}^y`L1F?,ATCR ST <br /> 20255388 <br /> i 'r`!';zYvC '..3+`o4 195 B. State Genera�orslD <br /> W) 4. Generator's Phone 45 'Z'7 I,,p <br /> `CN 5 Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID[Reserved.] - <br /> ao :) EN.'rE'T E T-eANSPCIP -A-M31l.ih,{� eiyrt�TC= <br /> o _A } R :j D. Transporters Phone frG -t <br /> 477 <br /> °P 7. Transporter 2 Company Name 8. US EPA ID Number J E. Stole Transporter's ID(Reserved.) <br /> M_ <br /> MQ F. Transporters Phone <br /> VV 9. Designated Facility Name and Site Address 10. US EPA ID Number Ghat a•• ' <br /> Q C:--!EM!CAL'V%(A=—�l ANAGE kIE NT.(i'•�f� . . <br /> Z <br /> .0Z 4-525'1 OLD S TUNE KtA ! H. Facility's Phone <br /> 0 K—E-1 TLEMAN C!T'?Ir 2 f: ' !m ! 4 i I d Sr <br /> ^^Q12. Containers 13. Total 1 d. Unit <br /> V V <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> No. Type Quantity Wt/Vol 1: Waste Number <br /> NZ a :'' N a:_ .A`-iAZARDOUS BBQX(3011 -.0N 1NATE0 state <br /> N E rb <br /> P7!1 <br /> C) N b. state <br /> m E <br /> v R Ezra/other;�, <br /> v A <br /> C. 5fb'fe"Y <br /> o T <br /> CIO 0 <br /> R <br /> Lu <br /> d' ^1� \ Sale is as x+ <br /> Lu V <br /> INA <br /> rV , EPAr"blheK' 4 ., <br /> Z, , - J. Additiona�De;criptions.For Material'Listed Above K.Handling,Codes forWa'stes Lilted Above r <br /> da.. ., b. <br /> j ,.; DLf,CFTA�iI ATf r, fTt TAIviceIT,+ ,ERs- i : <br /> r J f� c d: mss' <br /> Z <br /> 15..Special g Inst uctions and Add'Tonal Information <br /> O rNr�ar - jD�%e es as awYrop�?Ste24 HR M-Plad# - Lee caf—eS_ Rhfir. Tr <br /> Z Tran: .] r-O#i 35011j. T;-an 2 <br /> � / f <br /> 16`GENE TOR'S 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 ore in all respects in proper condition for transport by highway according to applicable international and national goverment regulations. <br /> J �' <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 /> 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 minimi my to generation and select the best waste management method that is <br /> Oavailable to me and that I can afford. i 1 <br /> V PrinkOT�y _fir$•, Sign'lure f Mont/�} Day Yea <br /> Q1E(I "t rf <br /> Z <br /> J '* 1 ,- 4 <br /> W T 17. Transporter 1 Aclor6 ed ement of Recei t of Materials <br /> (� R <br /> LU N <br /> Pr ded/Typed N� � /� b�f�� Signature v Month Day Yea <br /> W S v S U P <br /> P <br /> u_ 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name Signature Month Day Year <br /> W E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20. Facility Owner dr^ eralor Certification of recei t of hazardous materials covered by this manifest except as noted in Item 19. <br /> Y Printed/Typed Nam f�r `1 r fir / ��� Signature (�Jo �1 j Day( 17e r <br /> ¢ f'. <br /> / 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 3r0 days.) <br /> A I - 1 — A. <br />