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Sioie of talifornio—Environmenial Protection Agency See instructions on back of pa�.- Department of Toxic Substances Control' <br /> Form Approved OMB No.2050-0039(Expires 9-30-991 Socramenlo,California <br /> Please print or type. Form designed for use on elite f 12-pitch)t •riter. 2. page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> i. _arierator's US EPA ID No. Manifest Document N <br /> is not required by federal low. <br /> of <br /> WASTE MANIFEST F _ '} <br /> /5 �s r A. State Manifest Document Number <br /> I 3. General;oVmnd'Mailin dress. -�,, J"` -�: ✓: a^ ��xi._ !j1 ,(x94 <br /> l4 4 i� , P 3 r x tr` ' 7� j,,, 'T <br /> • L,?�r„^rift L; ��➢ r Q d3 fi 1 <br /> B. State Generator's ID - - <br /> � <br /> LO <br /> n 4. Generator's Phone <br /> 6. US EPA ID Number, C. State TransportePs aD Reserved,] <br /> N5. Transporter 1 Company Name , <br /> LO <br /> a <br /> yD. Transpr <br /> O <.�, _ .a e� r-n✓, nrx roEFs j 09.. .. <br /> p <br /> e o <br /> E. <br /> C? EState Tronsorfer's ID Reserved-� <br /> 7. Transporter 2 Company Name n ° <br /> F. Tianaporter's Phone, ` <br /> J <br /> J <br /> Q G. State Facility's ID . I <br /> V 9. Designated Facility Name and Site Address^^ 1 O. US EPA ID Num bar - <br /> Q � q' T`�l?1 E. AA M ng H: facility's Phone <br /> M <br /> :1 1 <br /> J 12. Containers €3. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Num6er) No. Type Quantity Wt/Vol 1. Waste 1Vumber <br /> -U -State { <br /> Z a, i <br /> .�-, EPA/Other' <br /> Oi <br /> State <br /> Eco, <br /> co N 6 EPA/Other <br /> w E � <br /> CN <br /> RA State <br /> c. <br /> OEPA/Other <br /> R State <br /> I � <br /> F <br /> Z _ EPA/Other <br /> LU <br /> V <br /> w K. Handling Codes for Wastes listed Above <br /> 4 sn 1. Add—canal Descri ff�pn�`s for Mptgriots Listed Aloovk <br /> O #t i t C. 1 1 } r ffa.l a f !tiE b <br /> � d. <br /> w c. <br /> W <br /> i Q <br /> Z 15. Special Handling Instructions and Additional Information Z C” q O F <br /> wC tt�1 � � <br /> ,� , MM ,� jet �_ � .:. .2-4� <br /> i = t��� 1w�Gr�a � av�✓�c��j° ��-Gr�`i��s��r �rJ <br /> a— <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,pace , <br /> Vmarked,and labeled,and are in all respects in,proper condition For transport by highway according to applicable internacional and notional government regulations. <br /> If I am a large quantity generator,I certify thoi I have a pr ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economics€I <br /> n practicable and that I have selected the Practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future4hreat to human health <br /> and the environment;OR, if I am o small quantity generator,I hove made a good faith efforttominimize my waste generation and select the best waste management method that is <br /> fc+ available to me and that I can afford. " _a <br /> O' Month Day Year <br /> Printed/T d Name Signature ,. 1 '""�' ,.�' / _ z <br /> I Z <br /> T 1 7. Trans orter l Acknowledgement of Receipt o Materials <br /> (� .�:„,e. ..q s Month Dox Ye <br /> or <br /> LU �" Printed/Typed Name{1% - Si alure, . ' ' .. w <br /> w P <br /> a_ g 18. Transporter 2 Acknowleclement of Receipt of Materials - Month Day Year <br /> T Printed/Typed Name - Signature <br /> I vw1 E <br /> Q R <br /> j U 19, Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> i 20. Facihty Owner or Operator Certification of receipt of hazardous-materials covered by this manifest except as noted in(tem 19- <br /> T Printed/Types Nome g ' <br /> Si nature Month Day Year <br /> - � <br /> Y . <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(1/99€ To: P.O. Box 400, Sacramento, CA . S15812-0400 <br /> EPA 8700--22 <br />