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05/10/2013 02: 12 FAX 1a003/003 <br /> II Slap of Califeenlo—Environmonlol Proleclion Agency <br /> "Farrri.App!bwed OMB No.2050-0039(Expires 9-3D-99) See Instructions on back s .ge 6. Department of Toxic Substances Control <br /> Please print or type, Form designed tar use on elAa f 12•plkh)typewriter. Socromenlo,California <br /> UNIFORM HAZARDOUS1. Generator's US EPA ID No, monlfesr Documonl No, 2. pogo 1 InFarmation in the shaded areas <br /> I <br /> WASTE MANIFESTisnot required by federal law, <br /> (' I -, I <br /> t 3 Ganeraloe'a Name and Malling Address / J A. $tote Mcn:fest Dccumenl Number <br /> ' F�u� �IUT'f �1'lFVru� r � v. „ <br /> S. SlateGanoratpr s 10 ����� , <br /> A <br /> Generator's Phone( I r�t C✓1 R'~aY <br /> N1 5 Tranaporler 1 Company Name d, US EPA ID Number C. State Transporter's 10[Reserved.] <br /> W <br /> p6 <br /> D. Transporter's Phone <br /> ! o til./ 4 E/ 0?qj <br /> 0° 7 Tranaporler 2 Comp4nj Name 9, U5 EPA 10 Number E, $fele Transparter'i I [Raserved. <br /> Imo— , <br /> N Q ,[ F, Tranapertera Phen � cSf _ C-"7I <br /> C co <br /> U 9 Dosignarod FactI4 Name and Silo Aiildre,tts 10. US EPA um er ,G. Srote Fael Ivy's ID <br /> Ld73 �rclva��Janl� (,,1t �JysIJaC:r <br /> z 7yL�U cifcr'S H. facilily'sPhone <br /> CfJ0 <J I J" _� P _ ( I <br /> C"J 11. US DOT Descriplion(including Proper Shipping Noma,Hazard No Class,and ID Number) Cvntviners 13. Toral le, Unit <br /> � No. =a Quanllry Wt/Vel I, `✓✓sate Number <br /> z a Stare <br /> s 1V6,4,1 f'� (J{d` �r!2 r r6, U[.5 LJirij 1 f /—I � ! <br /> 3 0 � /' EPA/Other <br /> C� <br /> o N 6' slab <br /> a? B EPA/Orllor <br /> v A c <br /> o T stole <br /> m O <br /> R EPA/Other <br /> oc <br /> LU d. Slee <br /> Z <br /> V EPA/Olhor <br /> Lu <br /> V) J. Additional Desirnpllons F9r Materials Listed Above K. Handling Codes For waslw ustod A6ave <br /> Z <br /> I V) a, b. <br /> i W , <br /> r <br /> aG <br /> � 1 C, d. <br /> 15. Sp -ciHondlinglnit�crionaandAddiltonal n6rmalion _ <br /> o <br /> Q j-re ry�'�^5 C'rs� r f!/ �. - tG; , r r� 75 <br /> Z <br /> w _ <br /> r— <br /> 16 GENERATOR'S CERTIFICA ON: I hereby declare Thal the contents of thiseensignmenl ore fully and accurolely described above 6y proper shipping name and ore tlosaified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condirlon for Iran sport Fry highway according to applicable inrernalionel and notional governmenl regulalians. <br /> d If I am a large quanliy generator,I codify Ihoi I hove a proDram in place to reduce the volume and loxiely of woste generated la tho degree I have donoemined to 6e economical <br /> d proclimble and that I have selected the roetita6ls method of kealmml,storage,or disposal currently availa6la to ma which minimizes the present and fvFuro threat to human health <br /> L6 <br /> and the envirenmemt OR,if I am a sma I quantity generator,I have mode a geed faith efforl to minimize my wase generation and seleci the 6e5l wasle monagomaril method thol is <br /> 0 availa6la to me and Thal I can offord, 0 t <br /> Printed/Typed Nvme Sign sr' Month Day Year <br /> I _ f s <br /> WLfy)f-'�qh` ir .w� rC r C>t f <br /> Vr R 17. Trani orler 1 Acknowledgement o Recei I of Materials <br /> w s Typod Name Sign e/ Month Day Year <br /> 12P <br /> L6 p 1 S. Trans rrer 2 Ac nowled ement of Receipt of Malarials <br /> O Ir Primed/Typ Name Slonature 7^ `Month Day Y-a• <br /> W E i U ti <br /> V <br /> F 19. Discrepancy Indtcalsov Spoke " <br /> i Z A <br /> 1 <br /> L <br /> f 20. Facility Owner or eralor Certificalion of rete) 1 of hazardous malarials covered by This manifest exce t as notad in Item 19. <br /> T Pr nled/Typed Nanie� r Signaturer r Month` Da(y� Year <br /> b0 NOT U41TE BELOW THIS LINE. <br /> Yellow- T5DF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A 11/991 (Oencrmors who subinil hazardous wade For Iransporl oul-of-stale, <br /> EPA 8700-22 product: completed copy of this copy and sand ro VT5C wilhin 30 days I <br />