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05/10/2013 02: 12 FAX 16002/003 <br /> - <br /> $iote of Colifornio—Environmantal Proreclion Agency <br /> Form•AppmvedOMS No.2050-0039(Expires 9-30901 $80 Instructions On back t dge 6• Departeentof Toxic SubslancssCowol <br /> Pleasa print or type. Form designed feF use on elfte(12•pitch)rypewriler. ;Saeramenro,California <br /> UNIFORM HAZARDOUS 1. Generelor'e US EPA ID No w,od;fest Document No 2, Page 1 Informmion in the lhaded areas <br /> is not required by Federal law. <br /> j WASTE MANIFEST i-S71 aF <br /> 3. Generator's N,�a''a and"ailing Address A°%Ia Manifest Document Number <br /> 7,1��7A-K'(�rDr'1 f �yC !� �1 rd1 �� `� <br /> rI rC GTS,'e `?J �`/ f- S. State Generators M i 4' .a ; : v <br /> Ln A. Generator's Phone ( ) <br /> ICV S. Transporter 1 Company Name 5, US EPA ID Numoer C, Stare Troneporrer's ID Reserrad.] <br /> l <br /> e+n Y. 'r°nspc ra <br /> 2 Company ae -r3. US EPA ID Num er E. ran orrer's ID(Reserred,]J r <br /> J 4.01 / A. 0F. Transporiar's Phon <br /> t V _,,,D�asigna Facility Name and Sila Address 10 US EPA Numbar G, Stale Facility's 10 <br /> LO d 1C-jv�r�-rs 1 r C� fr��rS�,rf <br /> 00 <br /> --sG�-' L- "-�S � H. Faciliy's Phone <br /> O <br /> Q ~ <br /> lilt 11. US DOT Doscriptian lincludl,pg Proper Shipping Name,Hazard Class,and ID Numbers 12 Canlain 13. Total ld Unit <br /> No. Type Quantity WI/Vol I. waste Number <br /> ° ,I'1/� Stele <br /> EPA/Olher <br /> N b.00 <br /> Stnrs <br /> co E <br /> Q R EPA/Other <br /> v A <br /> o T c. Slate <br /> CP 0 <br /> R EPA/Other <br /> d. <br /> Slone <br /> Z <br /> w <br /> V EPA/Other <br /> LU <br /> Z !, Addflional De►ar)prlene far Materials Lisled'Abore K, handling Codas for Wasles Listed Above <br /> O b. <br /> V) <br /> O 15. Special Handlloo Instru ions andoddilionalinformallon <br /> z <br /> / <br /> 16. GENERATOR'S CORMATI014, I hereby declare Ihat the contents of this consignment are Fully and accurately described above by proper shippina name and oro classified,packed, <br /> < marked,and lobelad,and ore in all respecta In proper condition Far Ironsporl by highway according to applicable Inlerealional and noriona government ragulalions <br /> -, If I am a largo quantity generoloe,I cerhy Ihot I have a progrom in place to reduce the volume and toxicity of walls ganseared to the degree I have dolermined to be economical <br /> CL. pracliceble and Thal I bare seladad the racticable method o treatment,storage,or dls sal currently available to me which minimizes the r <br /> V) ® Po hY p ascot and Future threat ro human heap <br /> and the environment OR,if I am a emailquantity generator,I have mad°a good faith effort to minimize my waste generation and seleel Ike best waste management method that is <br /> available to me and Ikal I can offard. <br /> ]- Prinled/Typed Name f Signaturej. - Month Day Yser <br /> LW <br /> CZJ <br /> T 17 Trons ower I Aeknowlad amens of Receipi of Materials <br /> LLJ Y P.6afRoyped No Signet j / Month Day Year <br /> Lu P } ti' <br /> CL 0 19 Trans orl°r 2 Acknowle emanl of Recai I Qi Maierla l _ <br /> 0 T Primed/Tyl Neme 5ignalure Month Day Year <br /> W [ / <br /> Q R - <br /> U F 19, Discrepancy Indication Space <br /> Z A <br /> C <br /> I <br /> L <br /> 1 20. Fac;IiN Otmer or Operator Cer_lificolion of receipt of hazardous materials covered l I)aie.manlFett—pi as nal in Ilem 19. <br /> T Printed/Typ I y a � j Signalur° ; <br /> �(�'/ �� / Month Day Year <br /> DO NOT WRITE BELOW THIS LINE, <br /> Yellov.: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC a022A (1/99) 10eneralors who submir hazardous waste for Ironsporl oul-of-slate, <br /> EPA 8700-22 produce compleled copy of this copy and send to DT5C within 30 days,l <br />