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State of California—Environmental Protection Agency SBB II15fifLCtIOnS 0[1 back Of f'rygd. Deportment'of Toxic Substances Control
<br /> Form Approved OMB No.2050-0039(Expires 9-30-99)„.
<br /> {. = Sacramento,California
<br /> 'Ve'ase print or��typ8. Form designed for use on elite f12-pitch)R,: a ter.- Manifest Document No. 2;-Pogo 1 Informaiion in the'shoded-areas
<br /> } 'Generator s US EPA IQ No. is not required by Federal 1041.-
<br /> UNIFORM HAZARDOUS 5. ,� of
<br /> WASTE MANIFEST , t: .;�.. I • y h N
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<br /> 0 15. Speciak,Handling Instructions and Additional information' i.
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<br /> 16: GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully a'nd accurately desc66ed above by proper shipping name and are cldssified packed
<br /> -,< markedand labeled,and are in all respects in proper condition for transport by h;ghwoy according+o applicable international and national government regulations
<br /> lace to reduce volume and toxicity of waste generated to the degree I have daterinbeeconomieoll ,y ;F
<br /> If I am a'large quant%!y generator,l certify that I helve o program in p yy
<br /> a prachca6le and thdt I have selected the p�r actico6le.method of treatment,storage,or currently available to me which in%ni itizei the present and future threat l method
<br /> heplth -
<br /> and the environment;OR,if I am a small guanlity generator,I hava'made a good faith effort to'mmimize-my waste-goner at;on and select the best waits management method chat is i
<br /> available to me and that I can afford- " :g
<br /> O - - Signature a - - Mont6.r'���� [J e4� "9
<br /> V .Printed/TYPed Name - ; �}'], ', - - -.,t !J
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<br /> 3 - T 17. Trans orter 1 Acknowled errant of Receipt of Materials
<br /> p _ Signature. r Month' Day Year
<br /> •'A Print d/Typed N nie _ s- -,r
<br /> 'O 0 18. Trans rter 2 Acknowledgement of Receipt of Materials Month Year
<br /> T Printed/Typed NomeWU
<br /> Sign re
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<br /> U19. Discrepancy Indication Space
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<br /> - " 20. facile Owner or O orator tification o ecei t of hazardous aterials c b t is m ca 1 as noted in Hem 19 nib - Day ' Year -
<br /> T Print ad/Typed Name ignatura
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<br /> DO NO WRITE B HIS.
<br /> 4 Yel w: TSPF SENDS THI5 COPY,TO GENERATOR WITHIN 30 BAYS
<br /> (Generators who submit,hazardous waste for transport out of stale
<br /> DTSC 8022A(1/99) proddce completed copy oFthis copy ono.send to DT5C wl+fiin 30 days 1 ;
<br /> .EPA 8700-22 =
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