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De r ^.�— •�` �- .. - ., artmaM1t Of TO%IC Substances Call .:;
<br /> state of California—Environmental•Protectlon Agency See IRstf Ucflons ct back b.. p Sacramento,California
<br /> _Form Approved OMB No.2050-0039(Expires 9-30-99) r
<br /> Please print or type.-Form designed for'w5a on elite(I2•pitch)i .!ter -
<br /> 1. i US EPA ID No.r' Manifest•Dacume
<br /> Generator' n!No. 2 Page 1 'Information in the shaded areas t
<br /> is not_require 8 by Federal law_
<br /> -UNIFORM HAZARDOUS // - of
<br /> WASTE MANIFEST ! '' �o � I b b- ;
<br /> f' A+$tote Mdmfes!Document Number g I�
<br /> 3. Gener r s Name and Meiling Address "y t�^�
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<br /> c 1�t- B �31ate Generator's ID ` � t� tik w
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<br /> r yet }` 6 US'EPA iD Number C' S►ahs Tsansparer fD[Re3e+veh , yvE of E
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<br /> � , 7 ,Additibriol Descnphons,For Matenirls LI 1-� '� x �' $^�,-x`�S�" -''b+r� t :':r. ,� �': '� A' � � �,1. .'
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<br /> z E 1 ERCTENCY ..EMP ►INS '
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<br /> - -16: GENERATOR'S CERTIFICATIONr 11heisby dedore.that therconlen s of this consignment are Fully and accurately described above by'proper shrppmg name and are class)led
<br /> yy trona
<br /> I and national 'avernmenl regulations
<br /> gg according to applicable rnierna 9
<br /> iti dFortransport-6 hi hwa ac g, pp -
<br />, V _ r marked;and lcbelad,and are in all respects In proper Gond oy 9 Y
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<br /> volume and foxici of waste'enerated to the dagiee'I'havWdeFern fined to be economical)
<br /> Ill am a large qu ntiy generator,I certify that E have a pr ram in place to'redu[e the ty g
<br /> a __ - _-'.µrodicable.and that I have selected the ppmtticoble method�t#eotment,storage,or disposal'currently avaifable;to ma which minimizasahe presersRancf-Future threat te.humdn health=-
<br /> and the environmenfj'OR,if.I am a sma11 quantity genercitcr,I have made,a good;foith effort to minimize my waste generation and select•the best.wasle management method that is {
<br /> available to me and that I can afford. - '
<br /> a� O - - T Monlh - Day -.Year
<br /> Printed/T ad Nam Sign urs � '-
<br /> p -`41c� e6
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<br /> li W
<br /> T 17_ Trans orter 1 Acknowled arrant of ecei t of Materials '' ° -
<br /> M th' Day Year
<br /> Pr' e T edNome Signator -.�t'i - �,.3
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<br /> tL .0 18.-Trans ortar 2 Acknowled errant of Recei Yof Materials ZL
<br /> 0 IR Printed/Typed Name ?' Y Signature - Month Day; Year
<br /> I V 19. Discrepancy Indication Space
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<br /> f - 20. Facili Owner orOperator Certification of racei i of hazardous rrateriafs covered 6 this m 'fest exce t as a on Item 19
<br /> Si ria a Month'- ' Day Year
<br /> ..TP r' Yped Name C + g
<br /> 'NOT.WRIHIE
<br /> IOW TH15.':LINE
<br /> Yellow: TSDF+SENDS.THIS COPY. TO GENERATOR WITHIN 30 DAYS
<br /> (Generators who.submit hazardous woste#or transport^out of slate
<br /> f DTSC 8022A 11/99) produce cotttpleted copy,of this copy and-send to DTSC within 30-days)'
<br /> —22
<br /> EPA 8700
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