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State of Cglifornia—Environmental Protection Agency <br />Form Approved OMB No. 12050-0039(Expires 9-30-99) See Instructions on ball( of Oge 6. Department of Toxic Substances Control <br />Please printer type. Folin designed for use on elite 02pitch�610r. 1 5,...�....s,. 11:1-:_ <br />DO NC (/WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIW36 DAYS. <br />DISC 8022A (1/991 (Generators who submit hazardous wafte for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />UNIFORM HAZARDOUS <br />US EPA ID No. Manifest Document NPW <br />2. Page I <br />Information in the shaded areas <br />WASTE MANIFEST <br />Jenorolor's <br />i <br />L S / O U a <br />' Of <br />is of required by Federal law. <br />3. Generator's Name and Moiling Address TO fN-<,< A6 / U y <br />A. State Manifest Document Number2280003'2' <br />� �i 4 0 ® ® � <br />2 <br />/ 9,2 1,4 r'!/it fid Aeo . <br />G V L <br />CA . 9 5-P G <br />B. State Generator's ID <br />.«rwxw. <br />A. Generator's Phdne '�� ) _ <br />5. Transporter I Cdgipony Nama 6. US EPA ID Number - <br />C, State Transporter's ID [Reserved.) <br />�POIOCIV C",OTitmi Industr{L s IDI 918121013101117 <br />D. Transporter's Phone 16101236-1393 . <br />7 Transporter 2 Company Name 6. US EPA ID Number <br />E. Stole Transporter's ID [Reserved.] <br />E Transporter's Phone <br />9. Designated Fa<iI Name and Site Address 10. US EPA ID Number <br />ECC3LOG? G6NTROL INDUSTRIES <br />G. State Facility's ID <br />2555 PARR BLVD <br />H. Facility', Phone <br />RICHMOND CA 94801 PA I Q 01019141616131912, <br />1 510 235-1393 <br />11. US DOT Description ncludin Proper Shipping Name, Hazard Class, and ID Number <br />P (: 8 P FF B I <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Val <br />L Waste Number <br />No. <br />Type <br />NON RCRA HAZARDOUS WASTE SOI.UD <br />Cm <br />state <br />WASTE EMPTY STORAGE TANK f't!� y�� <br />P <br />� <br />srz <br />EPA/Other <br />E <br />NONE <br />N <br />b. <br />State <br />E <br />EPA/Other <br />R <br />A <br />H 11 <br />T <br />a <br />slate <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/Other <br />�,dditional j� scii r s�Ear. ' 1 <br />PMPt YSi��"JHAtit zl°ANK #IlCit/ <br />K. HandlingCodes for Wastes <br />Listed Above <br />.1r. /e. �,....._...__.e_W�._ <br />TARIKS HAVE: SEEK! L? INERTE <br />a. <br />WITH 151,136 DRY ICE PER 1000,Ul AI.I.ONS CAPAt;.IYY <br />a. <br />d. <br />7aitc�tiVElraf, dilR MENT WHILE HANDLING. WEIGHTS OR VOLUMES ARE: APPROXIMATE, <br />24 !-HOUR EMERGENCY CONTACT: <br />24 HOUR EME:iF UENC:Y fELEPHUNk NUMBER.- J! N : Srt7�Gfs 5�� <br />16. GENERATOR'S CERTIFICATION: [hereby declare that the contents of this consignment are fully and accurate)y described above by proper shipring name and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to opplicable international and naliono government regulations. <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and tonicity of waste generated to the degree I have determined to be economical[ <br />I hove disposal to the future threat to human health <br />practicable and that selected the practicable method of treatment, storage, or currently available me which minimizes present and <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 is <br />available to me and that I can afford. <br />Pr ;d1Typede Na �/I -- <br />�T'NUJ <br />Signature �r� �r'. (� <br />r;ilk .,., <br />�t'F1H'�1 <br />Month Day Year <br />L'iXC. �-� <br />�4�Ct:(.. �� hl` 11UPt.9i6 <br />O <br />T <br />17. Transporter 1 Acknowled ement of Receipt of Materials <br />R <br />1p <br />Printed/Typed Nama. t <br />Signature _ -- <br />Month Day Year <br />s <br />3 <br />0 <br />'18. Trona oder 2 Acknowltidgement of Rece: 1 of Material"s <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />1 <br />20.. Facility Owner or Operator Certification of receipt of hazardous materials <br />covered by this manifest ezce t as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />Y <br />G 173, <br />DO NC (/WRITE BELOW THIS LINE. <br />Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIW36 DAYS. <br />DISC 8022A (1/991 (Generators who submit hazardous wafte for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />