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Sate of California-Environmental Protection Agency See Inslry8onB'Ori bock Of p b•- Department of Toxic Substances Control
<br /> Form Approved CtMB'No.2050-0039{Expires 9-30 99I e. _- Sacramento,California
<br /> Please print or type. Form designed for use on efite,(12-pikh); ;iter_
<br /> 9:"�enerafar's US EPA 4D!JB- Manifest Document No,- 2. Page 1 Information in the shaded areas
<br /> is not required by Federal law
<br /> UNIFORM HAZARDOUS � � kk � � of
<br /> WASTE MANIFEST . 1 _ '1 M
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<br /> 16..GENERATOR 5 CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shippping name and are classified packed
<br /> Q marked,and labeled,and are in all respects in proper.
<br /> For transport by highway according to_applicable international and national.government regulations` gF p
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<br /> IF 1 am a lorgeYquantiy generaror,I certify that l have a program in place Io reduce the valume'and'toxicity of waste generated to the degree I have defermmed to be economically
<br /> 0- " 'practicable'arid'thot 1 have'selected the ppracticable method of treatment,storage,or dispasaf currenlly available to"me which minimizes the-preseni and Futpre_Ihredt to human
<br /> N and the environment;OR,if Lam a small quantity,generofor,i have made a good.Faith effort to minimize my waste generation and select the best waste management,method that is -
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<br /> ae available to me and that, can offord. s .
<br /> -Mont .1Doyf/ Year:
<br /> Printed Name :. Signa C
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<br /> w T 17. Transporter 1 Ackripwledyferniini of Receipt of Materials '
<br />{ R Si nadir Manth�j Ray Year
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<br /> A -Printed/T ed Nome � g Il!/
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<br /> p - is. Trans rter2 Acknowledgement of Receipt of Matericls
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<br /> O R Printed/Typed Nama Signature Year
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<br /> V 19, Discrepancy Indication Space ' c
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<br /> ! 20. Facility Owner or Operator Certification'
<br /> of recei t of hazardous materials covered 6 this monifei ce t noted in It' 19.
<br /> I T Printed/T Nome - - - Signatu -Month -
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<br /> DO NQ -WRITE' BELOW THIS LINE
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<br /> Yelfow: TSDf.-SENDS-THIS COPY TO GENERATOR WITHIN 30 DAYS
<br /> pTSC 6022A f1/99] IGeneratars'who'submit hazardous waste For f apsport out-of-sfcte }
<br /> produce campleted.copy of this copy and to DTSC within 30 days:]
<br /> r EPA 8700-22
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