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<br /> State of ealifornio—Environmental Protection Agency _�., w
<br /> p°4''hSeB Instruc4ions on bac o age P Sacramento,California.
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<br /> Form Approved OMB No.2054 4639„f Expires 9.30 991 �r k-.
<br /> P type. g Manifest Document 2. Page 1 information in the shaded areas
<br /> Please riot or e. Form designed For use on elite f 2- itch 1` y(erat— 145 EPA ID rNa is not required by Federal law.
<br /> ' k • UKIFORM HAZARDOUS of
<br /> WASTE MANIFEST �` 'A. C? a r Y
<br /> Ax State Ma f F D ement um'"r "r�A 2,i,�,ty!` -
<br /> 3. Generator's Name and Mailing Address }.y ry �t t
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<br /> 4.:Generator's Phone ( C State Tranaporser s ID[Reserved( as _
<br /> i. US fP_A ID Number ;y
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<br /> 9, Designated Facilily,Name and Site Address
<br /> i� L3T: H rFactlFry!s Fhone vt i 01I
<br /> Tr330 W. I7th Street
<br /> Earl ' Ba3 CA. 999 1 a' 14. Unit
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<br /> z15, Special Handling Instructions and Additional Information • 1 ► ?/
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<br /> CERTIFICATION:
<br /> - , classified,
<br /> ified,parked,
<br /> NO `FOedchrconsignmentcoynY P rPp g
<br /> or coed" ooFor transport by highway according to applicable international and notionogovernment regulatons
<br /> marked,and obeledand arein alapectsin prop
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<br /> ( have determined to be econom'scall
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<br /> If 1 am a laige quantify generator,l certify that I have a d of treatment,
<br /> in place to reduce the volume and toxicity l waste genek mi'ro the degree l h
<br /> practicable and that t have selected the ppracticable method a4 heatment,storage,or disposal currently available to me which minirisiies the present and future threat to human heal
<br /> ` and she environment;OR,if I am a small'quantiry generator,I have mode a good failh effart to m_inimiza my waste generation and select the best waste management method that is
<br /> •- o' " available to me and that I can afford. .
<br /> O - Signature; t if - _ Month Day Year —
<br /> Prin}ed/T ped Name .. 7
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<br /> T 17. Frans oder d Acknowled ement of Recei t of Materials
<br /> O Moth Day Year
<br /> R Signature /
<br /> w M Printed/Typed N me ` r - �.
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<br /> p18. Tran's orter 2 Acknowledgement of Receipt of Materials 'Sig nature Month Day Year
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<br /> O T Printed/Typed Name
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<br /> V 19. Discrepancy Indication Space _
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<br /> 'f 20. Facili Chvner or O erolor Certification of recei t of hazardous materials coveredb'
<br /> � ,.dhis.manifsst exce t as noted in Item 19. Month. Day ..Year
<br /> Signature
<br /> T Printed/Typed Name g
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<br /> �. DO-NOT WRITE BELOW THIS LINE. "{
<br /> Yellow: GENERATOR RETAINS
<br /> DTSC 8022A(1/99)
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<br /> EPA 8700-22 ,
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