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<br /> $tate of California—Enviranmentol Protection Agency � ; .- � ^. SacramentorGalifornia
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<br /> Form Approved OMB No.2054 0039 f r use o 9-30-99)to(12 P rifer.
<br /> Please print or type. Forrrdesigned for use on elite f f 2 itchl.' Manifest Document'Ni 2. Page 1 information in the shaded areas '
<br /> ltieiator s US EPA ID No. is not required by federal law.
<br /> UNIFORM HAZARDOUS � � r . 1 ! °f
<br /> WASTE 'MANIFEST _ l
<br /> 'A�Sfafe Manifest-pacument Number
<br /> 3. Ge tar's Nta�mp and Mailing Address
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<br /> h 4,'Generator's Phone f � it y C Stare T_ransporter s ID eserved] r a 5,
<br /> f\ 6. US EPA ID Number
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<br /> 7. Transporter 2 Company Name
<br /> Q ;F ransporters Phone ' s
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<br /> Q �G State Facehty s,TD� r4i r�• 'au 4e Y'
<br /> 10. US EPA ID Number 4 , f} pi arc Tc
<br /> OttV 9.'Designated Facility Name and Site Address jF� N �l
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<br /> t�Q ° No. T pe Quantity Wt Val rl Wasie'NumbeY '�6 ":2.
<br /> 11. US DOT Description
<br /> [including Proper Shipping Name,Hazard Class;and ID Numbed - State,
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<br /> Instruct"D and Acddhagal f align T{J .S4I:•:� ONSE+ -
<br /> 5 59')4-99-0240
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<br /> 16. GENERATOR'S and fabeled�FandToreNin all B espe[fscinrproper condition kr irsansport by highway according torappfi able international yand not onlal go a nment regulatnome and ore laa^sfied,packed,
<br /> If I am a large quaati generator,I-certify iliat I have a pr ram in ploce to reduce the volume and toxicity of waste'gench mi to the degree i have d Future
<br /> be human Ball
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<br /> �' practicable and that Rave or,
<br /> the racricable method of treatment,storage,or disposal currently uvaiiable to me which minimizes the present and future threat ra human heap
<br /> and the environment;OR,if I am,a small quantity generator;I have made a good.foith effort to minimize my waste generation and select the best waste management method that is
<br /> p .> O avoilo6le to me and th_at I can afford.-
<br /> r� Month Day Year
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<br /> } Prin�id Ted Nome . .moi .„ l - L}
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<br /> ' O 8 - ,17. Trans otter 1 Acknowled enient of Recei t o{.Materials Month p Year_
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<br /> 18. Trans orter 2 Acknowled ement of Recei t of Materials Signature Month Day Year
<br /> 0 R 'Printed/Typed Name
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<br /> } V 19. Discrepancy indication Space
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<br /> 20. focili pwner or O erator Certification of recei t of.hazordous materials covered b this manifest except as noted in Hem 19. t Month Day Year
<br /> T Printed/Typed Name . ' Signature iF
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<br /> DO NOT WRITE BELOW THIS LINE.
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<br /> 1' Yellow: GENERATOR RETAINS
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<br /> pTSC 8022A(1/99)
<br /> r, ' EPA 8700-22
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