|
stare of califarr ia—Enviranmentat Pratecfia"agency See Instructions on backof ^4ge o. iep°`°"sa«amento,Calilor"ia
<br /> Form,Approved OMB No.2050 0039{Expires 9-30-991 rifer: l 1
<br /> v Please-print or type. Form desighed for use o_n elite_f 12-pdcFl v Mamfesf Document Nc 2 Page t lnformotion in the shaded areas
<br /> rotors US EPA ID No is not required 6y Federal
<br /> UNIFORM HAZARDOUS #.
<br /> I + 2NN
<br /> of
<br /> -WASTE MANIFEST . {' O Y�
<br /> A stag Manifest po¢umeni Number _ f
<br /> Gem,ngyr�tfisN6nne'andMtailingAddFre_ss '= '�'^'f' l ,1,..1{,)f�.(�'•�p't t "'r� }^4,j' pias-
<br /> f'= 1 e $ Orate Generators!R
<br /> * � °' t:✓fY i�i 1trY2.t<etri' iii , }yt� t5. -G aY
<br /> .'Oi,
<br /> vto.
<br /> j 4 Generator's PfioneV('�j '-1 ��+ ,'� `""� - -
<br /> G'Slate 'P
<br /> rter s ID[Reserved In ¢+ s er
<br /> n 1✓Fbl} 6 US EPA ID Number . ,.
<br /> _S
<br /> A0 (5559)499-
<br /> r D s e s o Com, a t�a
<br /> l pp [[tt,, A 9
<br /> ` r r
<br /> ..W 5 a9 i°'<ir �YL7 .r.. - ? n'tF ,x�"-1,
<br /> 0 Er date Transporters IDylResersed] ate. � v �
<br /> m 8 US EPA ID Number --_T� ryx� M1Xs `
<br /> 7: Transporter 2 Company Name
<br /> e
<br /> _
<br /> lit.' e%s-
<br /> 10 US EPA kD Number L „G Stade Fac lity's�ID, �
<br /> ♦k/ryV g peslg grad y, arae ands ite�� `
<br /> 4 Fi' �Lu���T'J'Y -
<br /> CQ
<br /> Q
<br /> 0 .' ' xr° w t_'"' Y
<br /> 93648
<br /> _ r'^3 , ( -
<br /> J M
<br /> 12,a Corn ers i3:Total a14. Unii, y y
<br /> Q 11.:05DOT Description{including Proper Shipping Name,Hazard Class and 1D Numbed _ No T e,- Quantity Wi/Vol i Waste'N " -i"'
<br /> 5rate4 auk"
<br /> K,
<br /> >7 1tCPAZoti M,
<br /> Ttcr Ir; last f xc �' R 1� � ttl
<br /> " EPA/Othz
<br /> E bx
<br /> R
<br /> State'S. Awa 4
<br /> w
<br /> +.Z EPA/ �F
<br /> '.
<br /> - vC.ksPF , 'K:r.Horidlm .Gode'foastas. stedk -Akov
<br /> .�;•
<br /> g
<br /> s, fisted AbcJe`
<br /> ons'.{or Material �
<br /> ,. J Addrtional'pesc iP. -
<br /> ., �ti:'-y "'V '� rm.�- r• �x �"-,�,. s i 3,r�n, •t v.� Ir. ,ax' a 's-, -;.73' �,
<br /> '� .JL4.,:, ;*'- `.�"i's-.t•: .ry- rs, ,} i'a'�,',r.,*�",:.l,r d;�..M�r:•' t�.r-4'T.d�✓�D!f2�; »d:�,7i Ly�1� 'kk i"3-, i ,a1 .?�:'-.e, r +.-$'-i:ai-'aFisv^ �` _<<E :.,�'
<br /> t ° -'rF µ.V ,•" �i .z ,,x�,n 'q'4g'y;y'-$.,-t,�` 1,g3.,x ix+y} '1 :--:4, - '�-' i etv � _ .
<br /> R. r,'x, v,-rr - z
<br /> ,}- y/�' -'k g •. !V is✓, 4,
<br /> r d ,•=9s'f.ly-.K .', r�Nxsr'v,�. -a,G�s A ,- ''r,,,tr• xs('�/✓#itfn;a'wti, 'r�1.s-3' •2s,t. M,.i,.. -�zj;�.•s :%h:i•2..:.;{�r<as r�::4 5 ,.
<br /> xZ�r,;; - r - �iy3h i a`Ad ,rl,'.,'° .; .-i_�, "<rt'r„ i,en ,u o a - K•-,
<br /> •� '" r-- yrr..Tt-y �-�f,-.5 .gi:kr;�,� ., ��=?1%kti'.,.•Eiu'.%'ao.r7,'. xa c,i� at� �.ur.'., •¢-x� F-t`:Fd � '�h�,��"'
<br /> i .}'- 1 r f - r ;. r 'aY �,w.F,- e-
<br /> ,-d• ."vF 7"rr "•Y r--��- ,P ir�7 :!s_ "lr.:yY', * " ' ` ,±„i'
<br /> �',r...;?.�}r �..., cc'N�d!';.�, .�rFt.ru cr .x�v4:+c'�.Y;;-�..e•f,t,-_ rn.�'I��E �.,,a waa:r,� ,4?,�,.t'=-.F ri...h-,s w,�a,+��
<br /> Adstl I.Infor ilar4RVSP SE;
<br /> - ' 1
<br /> a >t7JJt }., ar� criIrr. �cvct '
<br /> I�S�i� iccalr140
<br /> {
<br /> k
<br /> t— ' re ala
<br /> ssified
<br /> ac ed
<br /> -ro er sfii I in Home and a .P
<br /> scribed-above b p .9 - -
<br /> } ..1'd. GENERATOR'S,CERTIFICATION: I her declare that the contends of this consignment are full and accorapplic e y P P ,,-,, p
<br /> 1 Q. marked,and labeled,dnd.are+n all respects in.proper condition for transport by highway according to applicable international and nplmnai government regulations
<br /> ca
<br /> If 1 am a large' uanfittyy generator;1 certify that.k have a pro gram in(place to•reduce the volume and tox�cityble;top ne which m n mizes teh.'ioied'to the dh epresentand futurre'ihreat bo human hlealfh --
<br /> d' practicable n�ll+at I'ha4e
<br /> Selected the ppracticuble method of treatment;`storage,'or disposal.currently avails
<br /> t.
<br /> iu� and the'environment;OR;if I am a small quer lily generator,('"have mode o good Faith efFo�1 to-minimize my.wgate generation'and select the best waste manogemeni method that is.
<br /> 1 ae t :'available fwhie'and that 1 can ciffdrd. " r
<br /> Printed/Typed Name
<br /> Srgnot 'e - ,y Month Day Yeor
<br /> w
<br /> .. w
<br /> T •'17. Trans otter I Acknowled ement o4-Recei f f Materials '
<br /> R Month - Day Year.
<br /> Printed/Typed Name `. - Sig' re
<br /> LU
<br /> J.
<br /> W
<br /> ti 0. '18. Transporter 2'Acknowledgement of Receipt of Materials - Month `Day Year
<br /> R Signature
<br /> A 0 T r Printed/Typed'Name71
<br /> ' - - .
<br /> rq F
<br /> U. ,19. Discrepancy'Indication Space
<br /> ..20. Facili Owner or O ercitor�Certification of ee.i 1 of hazardous materials covered 6 this manifest except as noted in Item 19: Month = xDay, Year
<br /> T ;'Printed/TYPed6Name` - ...' . Signature
<br /> Y
<br /> �.
<br /> DO.`,NOT WRITE "BELOW THIS LINE. .
<br /> _t Yellow.- 'GENERATOR'RETAINS ..
<br /> 'DTSC Sd22A;(1199)'
<br /> EPA.6700-22-'
<br /> d: - - - . .,.��......r=�. .�,--_ �'—�."-- .�.—...._.-.�.�-•,.-,•--.—,r—•-,�,�--nom.
<br />
|