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1. See Instructions on backat page o• tea+ o
<br /> Stnlebf>alifomia—Environm ntal Pro tfeection Agency Sac}omenta,California
<br /> Form Approved OM8 No.20039Ff Expires 9-30-991 trier. - �-• _ ,
<br /> Please print orYype; Farm. esigned for use on elite{12 pitch y 2 po e 1 Information in the sfiaded areas
<br /> neratoi s US EPA IP'No Manifest Document , g is not required by Federal law.
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<br /> UNIFORM HAZARDOUS: - of
<br /> WASTE MANIFEST. C wA T tea` �1 P.
<br /> g5ta N16nrFes�S poc4ufie�nt Nur�rtbejp� n t
<br /> ' VIS nI Mailing iAL"d{d�rCe:sEs
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<br /> 4..Generators Phone I. rr31 A� G ! US EPA ID Number
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<br /> C'45 ,Transporter 1 Company Name f - sn, a
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<br /> m Ei15ta}kTrgnspor#er s ID[Reserved]s y as A n$
<br /> 7:Transporter 2 Compony'Name
<br /> 8 .US EPA 10 Number a YY,Fj n gig 'sna �{{
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<br /> Q 10 US EPA ID Number
<br /> V 9. Desi noted Focllity.Nameand Site Address
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<br /> 12:Containers -13. Total ' 14 Unit" alt P M� s
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<br /> No T 'e" Quantity Wt/Vol. I WasreYtumbe
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<br /> Z15. Speunl Handling Instructions and Additional InFormotion'.'Jo .0. =61 •
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<br /> } ERTIFICATION: I hereby declare that the convents o4 this const IV,
<br /> are'fully and accurately described above by proper shipping name and are c ossified,pocked,
<br /> 1 b. GENERATOR'S C g y II
<br /> ' V marked,and labeled,and ore in all respects in proper-condition For transport by highway according to appSiwble Internatlonol and nationa'government regulvtlons. -
<br /> the volume and"taxicify of waste-generated to the degree I have determined to.be sconomicall
<br /> r - If I am o large quanti generator,I certify
<br /> that I have a pro ram in place to reduce _
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<br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and Future tfireat.to human heath
<br /> and the environment;OR,if I am a sural!quantity generator,1 hove made a good faith effort to minimize'my waste generation and select the best waste management method that is
<br /> available to me and that I can afford.
<br /> O Month Year_,-
<br /> Day .
<br /> Pr' -d/TYPed Na a Signafu�¢�r�-
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<br /> LLs T, 17. TransI rter 1 Acknowled ement of Receipt of Materials Month Day _ Year
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<br /> '. , Print T ped Na e _ 'LU
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<br /> R 18. rans orter 2 Acknowled ement of Recei t of Materials
<br /> li Month Day Year
<br /> .Printed/Typed Name -Signature -
<br /> 19. Discrepancy Indication Space
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<br /> f { I 20. Faci[i Owner or Operator Certification of recai t of hazardous motarials covered !"s.manifest exceat as noted in Item 19. Month boy Year
<br /> 5ignature -
<br /> T,; Printed/Typed Name -
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<br /> DO NOT WRITE BELOW THIS 4INE.
<br /> V.
<br /> " Yellow: GENERATOR RETAINS
<br /> DTSC 8022A 11/99]
<br /> EPA 8700-22
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