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State of California—Envirgnmental Protection Agency see Instructions on back OL "T9e 6. 1 epartment of Toxic Substances Cor <br /> Form Approved OMB Nj.2050-0039(Expires 9-30-99) Sacramento,California <br /> Please print or type. Fors.4.;v d for use on elite(I2-pitc. writer. <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 In n the shaded areas <br /> oft required by Federal low <br /> UNIFORM'HAZARDOUS rrr J /) ,'�") 'f 1.' l i <br /> WASTE MANIFEST L. �L, V / h <br /> r r A. Slate Manifest Document Nu Der (�7 <br /> 3. Generator's Name and Mailing Address _ Y% L :V:.1��� r T I,f J - <br /> 218 <br /> B. State Generator's ID <br /> O - <br /> in <br /> tr 1 <br /> In 4. Generator's Phone i <br /> N S. Transporter i Company Name <br /> 6. US EPA ID Number C. State Transporter's ID[Resery d.] <br /> ao r',f. '�Itf t....l :.r�.. <br /> f _, t!! C. D. Transporter's Phane <br /> C> <br /> O 8. US EPA ID Number E. State Transporter's ID[Resery d.] <br /> C? 7. Transporter 2 Company Nome <br /> F. Transporter's Phone <br /> V 10. US EPA ID Number G. State fcOiy's ID; t`y :J <br /> 9: pesignQ(ecI F,Qc![iy flolrte did;Site;Address; I I I <br /> H. Facili(y's Phone <br /> Z . i,A Cy 0 �} <br /> C*LL- '1 12. Containers 13. Total 14. Unit <br /> V 11. US DOT Description(including Proper Shipping Name,Hazard lass,and ID Number) Na Type Quantity Wt/Vol I. Waste Number <br /> State <br /> Z *}r�^•i !: )tr, I.1A?Aft00"JS WASTE L-fo flrf / <br /> = i vv'IsjF..]t ' /[> f EPA/Other <br /> t= <br /> 3 G State <br /> E ---- <br /> O N b EPA/Other <br /> coE <br /> v R Stole <br /> v A C. <br /> o T EPA/Other <br /> O <br /> R State <br /> w d. <br /> Z EPA/Other <br /> K <br /> LL <br /> V <br /> W K. Handling Codes for Waste Listed Above <br /> N J. Additional Descriptions for Materials listed Above i t) b <br /> Z C3ii..Y'J ATER a <br /> d <br /> V) c d. <br /> W <br /> Q ' <br /> Z 15. Special Handling Instructions and Additional Information <br /> O _ <br /> Z (. .1 Y[ {;+r.;t..ill(•,V I)(..i h,]F ,�(1t.f' .1EY1 .r.41.}~ <br /> W <br /> _ <br /> 1proper-- <br /> - <br /> Q 16. GENERATOR'S <br /> nand labeled,CERTIFICATION: <br /> alleespectsc!n proper condi onare that the con tforFthansport by highway ais co nt are ccording g toand rately appli able,iintternationalyand nati ship ing ame and are <br /> gov nment regulations. pocked, <br /> V to <br /> d if I pract c a lable o d9hattl hevenselec�ed the p ct cable methodogram in pace <br /> treatment,storageto ,orad iposal currenthe volume tly available to me which mtoxicity of waste inimizes mizes hto the e pres nt and futureI have ree thdreot be <br /> Kumon hec <br /> and the environment;OR,if I am a small quantity generator,I have mode a good Faith effort to minimize my waste generation and select the b st waste management method tha <br /> available to me and that I con afford. <br /> Signature ` 7TIt <br /> l ,�aY/.Printed/Typed Nome <br /> I <br /> LIZ <br /> tss T 17. Trans otter 1 Acknowled emenf of Receipt of Materials (vlonth-1 Day <br /> LLJ <br /> � A Printed/Typle NJam Signature <br /> NS <br /> w P <br /> . 18. Trans orter 2 Acknowled ement o[Recei 1 of Materials Signature Month Day <br /> O R Printed/Typed Name <br /> T <br /> V)LU E <br /> R � <br /> Q 19. Discrepancy Indication Space <br /> V <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> l 20. Facili Owner or O rotor Certification of recei t of hozar ous materials covered b this manifest except as note in Item 19. <br /> Month Day <br /> T <br /> Printed/Typed Name Signature <br /> DO NOT WRITE BELOW THIS LINE. <br /> I8022A (1/99) <br />