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<br /> State of California—Environmental Protection Agency St3C If75fi1 Ucflons'611 bQC�C O .RtJ��Wj Department of Toxic Substances Control
<br /> Farm App 1 '
<br /> roved OMB No.2050-0039(Expires 9-30-99} : -"� - .' Sacramento,California
<br /> Pletse print o�pe, Form designed for use on elite(12 pitch]• 4ter.
<br /> 1. Generator's US EPA ID No. Manifest Document No, 2. Page 1 Information in the shaded areas, i
<br /> UNIFORM HAZARDOUS ` is not required by Federal law. i4
<br /> WASTE MANIFEST . �y �7 W? e . °f -
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<br /> 1 M kA h$jate Mamfet Document Number A _ry '
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<br /> 12. Containers 13 Total IA. Unit
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<br /> ? � f. K Handlsng Codas for Wastes L_istea Above
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<br /> declare that the contents of this const nmenfore fully and accurately described above by proper shipping name and are dassihed,packed,'
<br /> 16- GENERATOR'S CERTIFICATION: I hereby g y tnotional and notional avernmant regul9Yons.
<br /> Q marked;and labeled,and are in all respects in proper condition for Iransporl by highway according to applicable iMe 13
<br />! If l am a large quantittyy generator,I certify that I have a pr ram m placetto reduce the volume and roxicily of waste generated to the degree I have determined to be economically "
<br /> rZ practicable and_lhat_l_hore-selected-the procticable method of treatmem,storage;or'disposal curiently avoilablo to me which minimizes ihe'present and future threat to human health
<br /> and the environ ent;OR,if 1 am'd.small qu°ntity gerteratar,I have nsada a good,faith affort.to-minimize.my waste generation and select best vrosle mcnagemenF method that is
<br /> available to me and that I can afford.
<br /> Month "Day. Year
<br /> )r Printed`�ed Name Signature ;y' ,
<br /> T 17. Transporter 1 Acknowled ement of Recei of Materials
<br /> A .Prnted/ pedName.,' 'r „s Signatu �<'- - _ MonLU
<br /> t .Day Year
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<br /> I O Q' 18. Transporter 2 Acknowledgement of Receipt of Materials
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<br /> T Printed/Typed Name Signptvre Month' --Day; Year
<br /> . (aj 19. Discrepancy Indicotion Space, -
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<br /> I 20. Focili Owner ar O erator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19
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<br /> Signature- Month` Day - Year
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<br /> .,. DO'NOT VRITE,,BELOW THIS,.LINE
<br /> DTSC 8422A(1/519) e Yehow GENERATOR RETAINS
<br /> EPA 8700-22
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