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No. 2050- 0039 (Expires 9-30:99 -7 <br /> yiov�ol lMU tI Form desioned r ` 4 Z / �'� ���• �'Department of Health Servlcps <br /> r— - —_ell ldc wriler) To Substances Control Division <br /> ' a UNIFORM HAZARDOUS '.�. Gane alae, US EPA ID No. Sacramento, California <br /> WASTE MANIFEST Mani 2. Page I <br /> • Do um / Information in the shaded areas <br /> M 3 °rJ�'e7IAr'q N a esd� yoA fB3 C is not required by Federal law. <br /> L H / Z 1, S Z 5 A. Stele Maniteel Document Number <br /> 3to b a AE . FiV NT oivr 'S <br /> S � TG �r 9 <br /> 4. Generator's Phone <br /> C /d S ouZdS` e. Slate Generators ID <br /> � (' � � ,•• L/ 2 S <br /> 5. Tignsporier 1 Company Nedr N <br /> L 1 L K C C N f A.V C I 6, US EPA ID Number C. Stele Trenspoder'e,lf) <br /> © (� 'S . ransporler'e Phone <br /> 7. Transporter 2 Company Name 7 DT � ..� <br /> 6. 5 EPA ID Number E. State Trensporter'e ID <br /> 9. IDes igneled Facility Name end Site Address p� F. Transporter's Phone <br /> L„ f� ) ( /� � (/ ,V Z-/`l C r zn1 ` S EPA ID Number G. Slate Facillly'e ID <br /> f ,eclllly's Phone <br /> 1c �^l 1,fn. pAr to CR / 9LrRo H, F <br /> ! � C A �+ pq <br /> eir <br /> I1 . US DOT Description (Including Pro 1 6 00 3 y/s - •'''� z 9per Shipping Name, Hazard Close, and ID Number) 12. Containers 13. Total iq, <br /> Quantity Unit Waste No. <br /> ' lis T� /r j' / No. Type WI /Vo <br /> a :, pry . Sroe � �� T9,vK Slee/ 2 <br /> E C� ( 1rbR Vr cL �(jGV4 4 ran BV.¢ 5nx_ o�, ,T y O D ! T r <br /> N <br /> R b ., ^ EPA / Other <br /> A <br /> T Stale <br /> O <br /> H r <br /> EPA/Other <br /> Slate <br /> d. EPA/Other <br /> Slate <br /> J. Additional Descriptions Cfor Materiels Listed Above EPA/Other <br /> OWW0Z FA' 0,60 L-/�45 041/vIA 719N ,rHandling Codes for Wastes Listed Above <br /> /000 44 ,c, &//r# pR y rC rca. <br /> 0l <br /> y d <br /> 15. Special Handling Instructions and Additional Information <br /> , e. <br /> GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are lolly and accurately described above b <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> inlernalional and national government regulations. Y Proper shipping <br /> It I am a large quantity generator, 1 certify that I have e <br /> Proamd eterrmined to be economically practicable and that I haves electedithe practicable to reduceace hmethod ofVolumeatreatment, storage,d toxicity Ofaogeneratedr disposal the <br /> rl ntlly available to <br /> which minimizes the present and future threat to human health and Ihapnvirollmenl; OR, It I am a; smell quantity <br /> faith effort to minimize my waste generation and select the best waste me 5 *19 Y generator, 1 have made a good <br /> Pr1ep(Tp gem9nl method Ihehls ev able t"a and that I can afford. <br /> IL�" Il rL lm� y1,O VClr r <br /> Simlaore <br /> I Month Do Year <br /> T , 7. Transporter I Acknowled (ll r/vvz�� t,.-� -' <br /> R Bement of Receipt of Materials '} <br /> A Prinle /Typed Na - <br /> N Signature <br /> S <br /> P Oh/ r`I Uty !} $ S Month Day Year <br /> O 19, Transporter 2 Acknowledgement of Receipt <br /> R of Materials <br /> Printed / Typed He <br /> E Slvnelure <br /> Month Day Year <br /> 19. Discrepancy indication Space <br /> F , <br /> A <br /> C <br /> L <br /> 1 20, Facility Owner or Operator Certification of recaipl of hazardous m llerials covered <br /> T Pri ,ed / Typed Name s enilesl except as n Idd In. 11em 10. <br /> ff /4 N /VX N pW Signature <br /> Month Day QYear <br /> IHS 8022A ( 1 / B7) <br /> PA <br /> 9095) Pa 86) Previous editions are obsolete. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 3 6AY INSTRUCTIONS ON THE BACK <br /> IN CASE OF AN $31"uh1. , CAF,), THa NAYII Nhir WggFryplyj/ py/WwR 1rbZbYrRAIA•ylYWA1 AVI'FNIli elr*fJpedidW r IzALL + .r/•o, na.K .vxl„r <br />