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State of C000mia—Environmental Protection Agency,' <br /> Form Approved OMB-No.2050-0039(Expires 9.30-991 See Instructions on back ofa e 6. <br /> Please print or type. Form designed for use on elite f 12-pitch)typewriter, g Department of Toxic Substances Control <br /> Sacramento,California <br /> UNIFORM HAZARDOUS 1 Generator's US EPA 1D Na. Mnnifest Document No. 2. Page 1 In Formation in the shaded areas <br /> WASTE MANIFEST _ :; _ „ is not required by Federaf law. <br /> ' _ L .� Ir f of ' <br /> 3. Generators Name and Mall n dress <br /> >r gAd\„I � <br /> \ . - _ _ . A $taaMonicumenl NumberfeseDo <br /> ” . "_: $,. State Generator's <br /> ID <br /> 4. Generator's Phone <br /> CV 5. Transporter 1 Company Name b. U$E <br /> LO PA ID Number C- State Transporter's ID[Reserved,] <br /> O <br /> i� :-J" v - - D. Tronsporterrs-Phone '-'•'� �" <br /> _ 7. Transporter 2 Company Name B. US EPA ID Number ~ E. Slate Transporter's ID[Reserved] <br /> VI :F. Transporter's Phone <br /> 9. Designated Faclli Name and Site Address _ <br /> Q _. ._;1j1;N�s;(.� Yt t r•L 10. U$EPA ID Number G. State f a ility's ID(. <br /> ad 11.i r5d I <br /> JQ -ate %r"' ', H. Fodlity's.Phone <br /> J -...•.,i-.. <br /> 'a 11. US DOT Description linc!udin Proper Shipping ! I 12..Containers 13. Total 14. Unit <br /> V P• 9 p Aping Name,Hazard Cass,and ID Number <br /> No. Type Quantity Wt/Vol 1. Waste NumberT •• _ .. .S_ .i '�.: i::iY'i�I y ..TIL° .St�fe'e <br /> 3 F fh.�,rt J 3� J f i'` IrkEP^'fsr�Other <br /> n N 6: <br /> m State <br /> co E <br /> V .A EPA/Other <br /> T c. - <br /> State <br /> co O <br /> R EPA/Other <br /> 04- <br /> Lu d <br /> Z State <br /> w <br /> V- EPA/Other <br /> Lu <br /> Zv) <br /> J. AddiF gnohD�scn P}�on3 only�a?ri.15 Listed Above <br /> O . Handling'Codes for Wastes Listed.Above. <br /> 9.K <br /> . b, <br /> Q c. d <br /> 0 15_Sp=eaiol Hpndl aq,lnkrructiorusan� ddiliana(Infor.ajion <br /> ,._ .:•t�e�,3�.a.':� ,-�'+:="i. :^'.rC—' <br /> Q , <br /> Z �RA <br /> =i?u? x ^PZ A s7-l.16. GENETOR'S CERTIFICATION: I hereby declare that the contents of Ibis consignment are fully and accurately described above by per shipping name and are classified,packed, <br /> V marked,and labeled,and are in all respects in proper condition for transport 6y highway according to applicable international and national government regulations. <br /> J <br /> If I am a large quantity generator,I certify that 16 a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economical)y <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human health <br /> ce and the environment;OR,if I am a small quantity generator,I have mado 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 /> Printed/,Typed Nome r r Signature <br /> Z �- .'CJ \ \'\'^•' \�• 's `\'•Y ,f s-�. i - - t-, �... Mont; DaY__ Year; <br /> uj <br /> T 17. Trans niter I Acknowlad ement of Racei t of Materials - _- <br /> R s <br /> I,yy A Prmte5U.Typed Name Signature <br /> �G g T /_ Month Day, Year, <br /> P r 3 <br /> 0 0 1 B. Transporter 2 Acknowlad emonf of Receipt of Materials <br /> O T Printed/Typed NameLu Signature o• •`• Month„ <br /> a <br /> Lo R DIC ENVIRONMENTAL FACILITY IN LOS Day Year <br /> V F 19. Discrepancy Indication Space - <br /> y r <br /> '` APPROPRIATE PERMITS TO RECEIVE YOUR <br /> L WASTE STREAM AS QUALIFIED OUR EPal <br /> I <br /> L <br /> I 20. Facili Owner,or O orator Certification of recoi t!o1:1azcr­1ou,materials covered b Is - s cT Printed/Typed Name SignatureY i' .� , Month Year <br /> Day.:.. l <br /> DO NOT WRITE BELOW THIS LINES` <br /> Yellow; TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (1/99) (Generators •aha submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 produce completed copy of this copy and send to DISC within 30 days.) <br /> T 'd iiBE 09t, 600SSej0 aI11a>1 dB0 :pI S0 SZ qaj <br /> i <br />