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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-.99' See Instructions 66-bar' 4 page b.. - Department of Toxic Substances <br /> Please print or type. Form designed For useon elite(12 typewriter. Sacramento,California <br /> 1. Generator's US EPA ID No, Manifest Document No. 2.'Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUSis not required by Federal law. <br /> ` WASTE MANIFEST L` S 3 /of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> Cl/ /S 7 z B: State Generotor;i ID <br /> to A. Generator's Phone �) 3 <br /> � vI <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> 07 <br /> D. Pho O <br /> m r <br /> a? 7. Transp er 2 Company Name 8. US EPA ID Number E. Tra sporter's.ID[Reserve .] < <br /> 00 — /� r <br /> Q `� ` l/ t / F. Transporter's Phone <br /> U 9.. Designated ci ity No a and Site Address nn 10. US EPA ID Number G. State Facility's ID 1, <br /> LOQ �rl�rr��i� b�� �QNS-i�✓ <br /> C0 oZc D� H, cility's Ph ne <br /> CO S <br /> =; 112. Contac 13. Total ° 14. Unit <br /> N U 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Type Quantity Wt/Vol I. Waste Number <br /> *° <br /> Z State <br /> °x!/6!'1/' ��.�// O Zq's- l9US �. 1-t/Q'Gf�� r <br /> 2 <br /> EPA ther <br /> 3 G _, / <br /> N E b. State <br /> o N <br /> 65 <br /> 65 E EPA/Other <br /> ASIF THE IMAGE DISPLAYED ISC. — State <br /> 0 p NOT AS LEGIBLE AS THIS ePAioihe� <br /> R OVERLAY,IT IS LIKELY DUE <br /> W d. TO THE POOR QUALITY OF THE State <br /> ZORIGINAL DOCUMENTS/IMAGE.LU EPAiot6er <br /> w <br /> V) J. Additional Descriptions for Materials listed AboveK. Handling Codes for Wastes listed Above <br /> O <br /> V3 <br /> LLJ <br /> C. <br /> d. <br /> a71 <br /> O15. Special Handlyg Instrucans andrAddihonal fa abon <br /> Q SyC �Tc� ro` s �'tr V <br /> Z <br /> LU <br /> 16. GENERATOR'S ERAFICA : I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quanti,y generator,I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be ecanomica <br /> CL. practicable and that I hove selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heo <br /> and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that <br /> available to me and that I can afford. <br /> OPrinted/Typed Name Signature Day <br /> T 17. Transporter 1 Acknowledge ent of Receipt of Materials 1 <br /> W 5 Pr ped Name fs Signatu Month Day <br /> w P U 1 <br /> LL. 0 18. Transporter 2 Ackno.ledgernenj of Peceipt of Materials <br /> 0 R Printed/ ped Name Signature Month Day <br /> w E <br /> N a I� <br /> 247 <br /> U19. Discrepancy Indication Space / <br /> Z F <br /> A <br /> C <br /> I <br /> . L <br /> I 20, Facili Owner or Operator Certification of re<ei t of hazardovs materials covered b this manifest exce t as noted in Item 19. <br /> j Printed/Typed Namey1 / r Signature Month Day <br /> r DO NOT WRITE BELOW THIS LINE. <br />