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D6partment of Toxic Substances Control:
<br /> State of CaliFornio—Environmental Protection Agency Sgg' n'struc#10[15'OF1 �]OC�C-OF Sacramento,California
<br /> Form Approved OMB No.2050-0039{Expires 9.30 991 2 Pae 1 ' Information"sn the shaded areas :I
<br /> P4ease print or.type. Form designed For use on aWe 112-Pitch ,tar Mamfast Document N g is nol'required by Federaldow:
<br /> 1. Generators US EPA ID No. : -n yy
<br /> UNIFORM HAZARDOUS
<br /> WASTE MANIFEST . - �,to
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<br /> Document Number, q��
<br /> 3. Generator's Noma and Mailing Address
<br /> 0 d. Generator'-s,Phone I I �.(� [.. + - . ` -* -
<br /> � ���' �� �C''Stats Tronspiirte�s:ID f eserved]°@ ��" �
<br /> 6 US EPA ID Number
<br /> 5_ Trans q d r5EZcoj
<br /> £ State-Trans otter s 1D]Reserved] K "' ,t: !
<br /> 8 US EPA ID Number -
<br /> C? 7. Transporter 2 Company Name
<br /> _ - F'r�7ransporter;s�Pl�one ' �5�i�,y,r + �' %�'F°�'s "r ,r•F'`�"' � ,f
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<br /> ame and Site Addras 10 US EPA iD Number,
<br /> 9. Desrgqated F uLty y -
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<br /> 14287 '. + 31iT]fLtit
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<br /> Parber, 336
<br /> .Unit
<br /> '12- Containers 13 Total 14. s '
<br /> �.0 ll. US DOT Description(including Proper Shipping Name,Hazard Class;and ID Number) Na T e Quantity Wt/Vol 'S'Baste
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<br /> rr"' P .q '?' s 'q '�r r✓ gk'y fi++'ik �v'i e"` A. h✓• t''fv+ $ x !y x f 'kb `h-.i`N->x° �x 4 k� �_.- 'rt c 1+�r- ,-,..
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<br /> 16- GENERATOR'S CERTIFICATION:1 hereby declare sm roh er conontentforftr is con l by highway acro di a toinent are fully and appli able in terror anal an d nar onlal Bove nment regulallonsfred packed F
<br /> Q marked,and labeled,'ond are in all respect p p s,.
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<br />' r ti that l have a r6 ram in place to reduce the volume andtoxicityof waste generaied'ro the dlae r to en°and futume'rb eat oehuman health`,
<br /> If I am a large quanti generator,l cer fy p
<br /> :o,. _ practicable and that I have selected the practicable'method o lthwe mad"storage',
<br /> a craaod{o h effort torminfm Zea my I�a generation
<br /> nland selear ihe:bast'waske ma:dgemenl methpd.that
<br /> "r' and the environment;OR,
<br /> lam a small quantity genarako 9
<br /> available to me and that I can afford.^'
<br /> 0 Year
<br /> , ronth Day.
<br /> Printed T ed Name"' Signature
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<br /> W - T 17. Tran orter 1 Acknowled emenk of RBCei of Materials -'
<br /> -. .. - - ..1Vlonth Day 'Year
<br /> P n1e I ped Name SignatuLU K IF r� fc fiiLrJ ?
<br />` w S (/► r
<br /> P cknowled e
<br /> 18. Transporter 2 Arrient of Rei t of Materials Month Day ec
<br /> .0 R Printed/Typed Name_ Signature Year
<br /> W .E.
<br /> V19.,Discrepancy Indication Space
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<br /> f 20 Foci! Owner or 0 eratorSCertiftcahon of races 1 of hazardous materials covere rs m st exce t as n to Item 19 Month Day Year
<br /> yped Name.,. . Is Signa e
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<br /> DO NOT:WRITE,BELOW:THIS LINE.
<br /> t Yellow TSDF SENDS.THIS COPY TO,GENERATOR.WITHIN 30 DAYS.
<br /> iGenerarors.who submit hazardous waste for Transport vut-of state,
<br />` DISC 8022A'fl/99) produce_ camplated copy of.this copy and send<to DTSC within 30 days.(
<br /> 'EPA 8700-22
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