|
_-- Departmept oHFaxlc Substances Control
<br /> Stale of CPUfomra-Enwrortmental Protection Agency SeB ITIs}ruc tons atit back O��'4� Sacramento Californi
<br /> Form Approv$d_OtJB No.2050v0039'(Expires 9.34 99] ter. ;
<br /> Please pile:or type 'Form designed for use on elite(t 2 pikhJ tr t 2. Pae 1 In in the shaded areas ,
<br /> t.Generator s U5 EPA lD Na', Manifest Document No g is net required 6y Federal law
<br /> CINIFORM HAZARDOUS / - of
<br /> WASTE MANIFEST_` s l a
<br /> �q{�.y,�y-, r'e`+� y�� A State Man+fess 9ocument i�4u�ber� /(y��[�'j
<br /> - �A 4!''l�h - FIV fIROA•Ill, 1+�^` r li'-4"�h W'h��b �r'� "d� ��`�bf ti '�7��-�-� '{
<br /> ..3. Generator's lame and;Mailing Address �� P �:7 W6 _-
<br /> . - ���C.'��r�'•eT`� �r�`�. A `�'4 IL] - 8"'y 51ate GenerPlor 5 ID!�_F E ��r`, h��,:s'� rs i �' ,.>>~ 't
<br /> C��'+�!"+'► P-4II
<br /> to
<br /> Lei A.-Generator's Phone_ I � [ State Transporter s`ID[Reser+red]- of z ';; pPp
<br /> n z{ 6 US EPA ID Number
<br /> Cy :5.,Tr nip
<br /> is J�4�f14�. 1t �1�'BiT 'L
<br /> -� Yom,
<br /> -� _ _ - .1"�n, ! : 1 �;�.i yF,y,'}..-__$ , 'Z'Sr1i�.y 4.•/
<br /> O - - - ;E f,Stata Trenaporter's 1D
<br /> m8 US EPA tD Number r iiia+ 5 s s .1
<br /> ter 2 Company'Nome - Nv
<br /> 7. Transporter "
<br /> F tTransportes Phone r s F axr� �Y
<br /> Designated facility Name and Site Address 10 US EPA ID Number
<br /> JQ �c3T�]�214`'87 E. 4 Mil*
<br /> 1, x }l s P "�a t R fi3a
<br /> Via. 93649: Q 2 I
<br /> o
<br /> Par,4arv `arta r n s i `
<br /> 12: Containers 13. Total ;-t4. Unite '
<br /> No T e Quantity Wi/Vol 1 .Waste Namber
<br /> it. US DOT Description[including Proper Shipping Name,HazardNume
<br /> Class and ID 'or
<br /> StoteF.w a i
<br /> �` P
<br /> I' Jz EPA/Other
<br /> " M.
<br /> c�>r�-RC`,RA:Ha7a drif� '��Fa tlr tig(Ad.tl ss,cil�la fixed C�Il
<br /> t j
<br /> Ci. r state
<br /> O N EPA/Other,
<br /> J A-
<br /> a0
<br /> v
<br /> State
<br /> =R '+
<br /> 3 x
<br /> C14 A ,
<br /> �.
<br /> O T EPA/Oth00
<br /> ers
<br /> R - i -J i
<br /> -d.
<br /> LU
<br /> .
<br /> EPA/Other i- s
<br /> Z
<br /> LU
<br /> ffandlmg Endes For Wastes Llsted Ahove'- x c z °"
<br /> .sJJ
<br /> (n ;J'-Addition-1,De`,cri¢'tions for Matenpls.Listed;Abovs ss6a fi.s.u✓r-5., Y t � s 4 4 r ra, t e s r s, r b
<br /> , t'f.-',e, ya' �5-
<br /> Z � .r"•„Tv id r ,�. M ?^a b� .5.f �f �'" _i _ tir; ,cdt•* wP�'�r y ,
<br /> •�,r + d. y; Ms ,er ��, ��u, r •a �-
<br /> 0 i[. X- - , ,('tA w w Ak
<br /> '7�rar.n""y,��y�Y`'' r�-''"n i�,,rN� `1�
<br /> - 0. ! + _ uIC � 'k,r�r`rx,• 7L, -_ _ :dr'� -
<br /> .'. -"c_ rtx'<-:p.,+- 3 *t-,$:3rd. q �.",-,,;�` �.,Y.,�x+,�`s,. r Yf-way, d r1� }5 T,I�Fy,ry+- ne.r5.',,' ���+�F_ayr,-
<br /> c + �x � h rLF y[_ �Pj �E t� c',i us a q4, H
<br /> W �f'' ::;. f•-ri' �,, r �'uw+; dyrr4.�ug�4-r, ;5 .r yr'� �' 1 l•-
<br /> • s,.�. - .,r� +,r rn � F,`7", {7.'� °P 4.. '•, h�k- � ..,y, z7. A oµas' -, u.>?r - �!.s;�-
<br /> -' r�,�,,TT'1R*1 r, "�J`k 2 5 a y ter, `Ni�c k y "'{t S_5 r•�" ,y N Mir k 7 r�..N•t<r r... :,fir - e-a •N*.
<br /> - .Q F"J �x `rxli�I�•"., 2 'spa- 3' - :: 'a,
<br /> q y��; 7, _
<br /> f- O 15. Special H n.+ g I fru io s n d ti n Irk mail rt T i.'1 t'7 �Ea' 1 E-.PONS
<br /> " San boa tin t x.Rec 'c r :(559)498 0240
<br /> z �AitFi 7' CVz > q
<br /> UJ t01 t)o .Pt C.C. t.1 .. a
<br /> fa. . alelyy
<br /> �'1 S:'GENERATOR'S CERTIFICATION:.I hereby declare-chat the condition for trans 'vrt�y highway accord g fo�appl;cable.descrinterna one by
<br /> nal onra�gova nment egulohons[red_packed
<br /> Vmarked,and labeled and are is all respects in proper co P
<br /> + y
<br /> enerator,l cerci that.l have a pro ram in`place to reduce the volume an loxlcity of Waste generated wf ch.m n mizas he preterit and feturee(hav, me'tl+dretaF-bo human health'
<br /> -� -IF 1 am�a large*'onhry.g p
<br /> i ti j practicable and that I hhova selected
<br /> the pr oarvGble method generator, o to made argoodaMdlh 91'11 orm mm ze�m ywasle genernfion and select tke best waste management method chat i;,
<br /> _ 'and the environment;OR,.if 1 a •,quantity 9 _ --•'.'' r - ~
<br /> 1 available to me and that I can offord
<br /> _ - - Month pay ..Year
<br /> d Name _ Signatur
<br /> Printed/Type
<br /> }
<br /> k :; R 17. Trans arter 1 Acknowle emenl'of Recei t of Materials - - _ ' Month Day -,Year -
<br /> Signature,'
<br /> x w Pripy�i Name S
<br /> l u.LU 0 1 B- Transporter 2 Acknowled eme i of Recei t of Materials Month Day Year
<br /> 0 ; Printed/Typed Nome e
<br /> 'nture,
<br /> in
<br /> w E
<br /> Vyy 19. Discrepancy Indication Space
<br />` l
<br /> i f 20. FPcili Owner or O orator Certification of recoi t of hazardous materials covered b the mantle xce i s noted in I m 19 -Month-'. ' -Day.. Year -
<br /> Signature" .
<br /> j T Printed/Typed Name:
<br /> DO_NOT WRITE BELOW THIS LINE.,`
<br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN.30 DAYS. :
<br /> r1 (Generators who'submit hazardous waste copy sFor transport out-of-stats,
<br /> f pTSC 8422A(1/491. " produce completed copy of this end to,DTSC within 30 days]
<br /> ffi EPA 8700-22
<br />
|