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late of California—Environmental Protection Agency <br /> arm Approved OMB No.2050-0039(Expires 9- 0-99) See Instructions on back of p' b. Depart ant of Toxic Substances Control <br /> lease print or type. Form designed f.-va on a lte(12-pitch)typ Sacramento,California <br /> 1. Generator's USE 1 No: Manifest Document No 2. Page I Informal n in the shaded areas <br /> UNIFORM HAZARDOUS / isnot rei wired by Federal law <br /> WASTE MANIFEST r' r rl f, 1 ) `( of` <br /> �„ A. State Manifest Document Number t. 1142467 <br /> 3. Generator's Name and Mailing Address '1 , <br /> ` <br /> LAI 5 i�� B. State Generator's ID <br /> l <br /> 7 4. Generator's PhoneO-( �� {"� �Y <br /> I' � rrl <br /> 5. Transporter 1 Company Name <br /> 6. 1,S EPA ID Number C. Stale Transporter's ID(Reserved.) <br /> p D. Transporter'"Phone <br /> 7 I',;.;f1tY `vrit,i.L:`f' �1''vr+,�-i]•;. fill.. 1 <br /> 7. Transporter 2 Company Name 8. S EPA ID Number E. State Transporter'"ID[Reserved.] <br /> J F. Transp"Pone <br /> J <br /> 1 G. Stats FF uh)ym 0yt A�c]efsi10. S EPA ID Number .1^t J; q 'i,i illi'{.1/�•1,J H. FacilitD .;%,'L .'iA,'&•f'r-. f fl :iS1'il12. Containersl 14. U it <br /> Q 11, US DOT Description(including Proper Shipping Name,Hazard Class, nd ID Number) No. Type Quantity Wt/V I I. Waste Number <br /> State <br /> ? I1A4'11AbU)iD(N VilASTF LIQUID i <br /> L A f) 11 j ! j EPA/Other <br /> fJILY WAI C-N h <br /> G r � <br /> State <br /> E b. <br /> Co E EPA/Other <br /> 00 v A State <br /> C. <br /> 0o T <br /> 00 O EPA/Other <br /> R State <br /> w d. <br /> Z EPA/Other <br /> LU <br /> V <br /> w K. Handling Codes for Wastes listed Above <br /> tn J. Additional Descriptions for Materials listed Above <br /> a. i.)1 b. <br /> O OILY WATE114 <br /> a- <br /> N <br /> w d.c. <br /> oc <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> 01-0 VE <br /> Z [MCRGLENCY PHONE 201y'.667418 7 <br /> LU <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of his consignment are fully and accurately described above by proper shipping name a are classified,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> V <br /> If I am o large quantity generator,1 certify that I have a program i place to reduce the volume and toxicity of waste generated to the degree I have d terminad to be economically <br /> Qi- practicable and that I have selected the practicable method of treat ant,storage,or disposal currently available to me which minimizes the present and uture threat to Kumon health <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 wast management method that is <br /> oc available to me and that I can afford. <br /> Moral Day er <br /> O Signa <br /> Prinled/Typed Name -- _ Signature <br /> - <br /> r <br /> ,.!. <br /> Z <br /> w T 17. Trans orter 1 Acknowledgement of Receipt of Materials <br /> R Si olure Month Doy Year <br /> w RA Printed/Typed Name t �1 Li <br /> M I ! ;w <br /> w s �.,., _ r 7 • -- <br /> P <br /> 0 p 8. Trans rter 2 Acknowledgement of Receipt of Materials Month Day Year <br /> R Printed/Typed Name Signature <br /> T <br /> w E <br /> R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt t of hazardous mo rials covered 6 chis m }fest exc t as note in Item 19 <br /> Month Day Year <br /> T Printed/T d Name Signature <br /> y / f , 01t� f 1, <br /> DO NOT W I BELOW H.!,, INE. <br /> DTSC 8022A(1/99) <br />