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State of California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back of p 6. Department of Toxic Substances Control <br />Please print or NnueoWorm designed for use on elite (12 -pitch) typ Sacramento, California <br />It CF <br />D� <br />ilGiY: LI :.n JLt CSi % OWVDFZ4 <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />'.produce completed copy of this copy and send to DTSC within 30 days.) <br />R <br />— UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No. <br />2. Page 1 <br />1 4 <br />Information in the shaded areas <br />isfnot required by Federal <br />A L B 8 9 2 5 3 4 : 5 <br />WASTE MANIFEST <br />3. Generator's No and Mailing Address <br />M., ac. <br />A. Stare Manifest Document Number p.,� <br />� � 4 � � y' <br />FA IC MAST A.b. <br />, <br />4111 9. BUY DR. <br />R. State Generator's ID <br />m� a, CA 9ma <br />4. Generator's Phone (29 W%24 QmLact' JIM QARIL <br />- <br />I� <br />y <br />5. Transporter 1 Company Name - 6. US EPA ID Number <br />C 5tatie T n porter's ID Reserved.] - <br />9C <br />MI's w FRVT,flC9lij�TbL YFCK. A D 8 a � i 5 <br />2 O 5 7 <br />D Transp f is Phone T` � <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transpoder's ID [Reserved.] <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address - - - - 10. US EPA ID Number - <br />_ <br />G. 5tck Focility's7D <br />7! 4 h _ - -- <br />RO91% Ar <br />- H. Fa<ili 's Phone <br />ty #5F9)d 15 G <br />9 4 5 <br />2 5 S 3 <br />Mi 1LT[D, C� 54383 T <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. Containers <br />No. <br />Type <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />1. Waste Number <br />a <br />State <br />G <br />Fill <br />EPA/Other <br />E <br />'' `k:Afsi� L1 <br />- <br />smteE3.YLI.S <br />EPA/CtherR <br />HUE <br />Pri38 E 341287 ERG# <br />a,> t <br />O 0 a S <br />r <br />A5tcte <br />T <br />Y 'f IPMEE .s�"°�_1 M TO <br />EPA/Other <br />�I]8F <br />O�<e <br />R <br />Prt19 E 3UB34 WA <br />ololl <br />d, <br />state <br />EPA/Other <br />Description, ter NA&cn' l: Listed A6n, <br />K. Handling Codes tos Wast., Listed Abov e <br />d <br />1 <br />15. special Handling Insfrucfions and Additional Information <br />s+a wa r3s-'v�9Sr ##: 13341�i 5iz:1 li7 :6 <br />16. GENERATOR'S CERTIFICATION: hereby declare that the contents of this consignment are {ally and accurately described above by proper shipping name and are classified, pocked, <br />international and national government regulations. <br />marked, and labeled, and ore in all respects in proper condition for transport by highway according <br />to applicable <br />r <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health <br />s <br />practicable and that I have selected the practicable method of <br />and the environment; OR, .if_I am a small quantity generator, I have made a good faith effort to <br />minimize my waste generation and select the best waste management method that is <br />available to me and that I can afford: <br />- <br />Printed/,Typed Name - <br />Signature <br />Month Day Year <br />Barter <br />s <br />T <br />17. Trane 1 Acknowledgement of Recei t of Materials <br />-. <br />Month Day Year <br />g <br />A <br />Printed/Typed Name Signature <br />i i O3 <br />j <br />R <br />5 <br />�-{� <br />._f Ca w. K S C f i i. - <br />- <br />P <br />g <br />18. Trans 2 Acknowled ement of Recei t of Materials - <br />Month Day Year <br />TPainted/Typed <br />.d Name Signature <br />E <br />R <br />j19. <br />Discrepancy Indication Space <br />F <br />= <br />A <br />- <br />I <br />I <br />L <br />20. Facili - nor or Operator Certification of tecei t of hazardous materials coveldd b thu except as noted in Item 19. <br />1 <br />T <br />ranifesl <br />Printed/ ped No.., Signbit[sre <br />Month Day Year <br />Tr <br />1 <br />ilGiY: LI :.n JLt CSi % OWVDFZ4 <br />DTSC 8022A (1/99) <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />'.produce completed copy of this copy and send to DTSC within 30 days.) <br />R <br />