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De arlmenf of.Toxic Su stancesControl
<br /> .State of Cafifarnio—Environmental Protection Agency See InpHictiolns On back of-p1ge 6' p Sdtiam"enPo;iaiifornio
<br /> Forrti'ApprOved OMB No.2050-0039[Expires 9-30.99f
<br /> Please print or type. Form.designed/or use an elita f l2 PiFcf! trer' Manifest Document N 2. Page 1 Information in the shaded areas,
<br /> �_� t lerafor's u5 EPA 1D No. is not required by Federal law,
<br /> '"'' UNIFQRM HAZARDOUS. ..
<br /> WASTE MANIFEST '40 '
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<br /> �' `�V .11. US D_OT Description[including Proper Shipping Name,Hazard Class and ID Numbed
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<br /> 1 15.:Special Handling Instructions Additio/n-alglnformation _ a-� 7, •�, •� ��i Ell'1201L, �,
<br /> -0 ,�{� Y'y O' ; Y 4.'1�SJ l, i�i�.-Te�l'S7.� V EMERGENCY d L:.t3�1.f1'Y aim: .. -
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<br /> 16. GENERATOR'S CERTIFICATION, I hereby declare that the contents of this consignment are Fully and accurately described above by proper shipping name and'ore classified,packed,
<br /> _ marked;and labeled,and are in all respects in proper condition For transport by highway according to applicable international orsd national government regulations.
<br /> .'.
<br /> If l am a large quaMiYy generator,t cerlihj that I have a program.in place
<br /> to red fee the volume and toxicity of waste generated to the degree I have determined to be economically
<br /> a- practicable and that I have'selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human heahh
<br /> and the environment;OR;if I am a small quantity generator,'I have made a goad faith effort to minimize my waste generation and select the best waste management method that is
<br /> available to me and that.I con afford. f
<br /> - r.. _ - _ _w _ Month Day_ Year Q f'ri ed Name��rw� Sigrt are "� 'C�3/ iJ
<br /> w T 17. Trans orter 1 Acknowledgement of Receipt of Materials
<br /> - Sigagt�re`✓ s Month Day Year
<br /> wA P•riryte /Typed NorgeLLJ
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<br /> U- 18. Transporter 2 Acknowledgement of Receipt of Materials - - Month Day Year
<br /> . rR Signature
<br /> T Printed/Typed Name
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<br /> V19, Discrepancy Indication Space
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<br /> l - O erator Certification of recei t of hazardous materials covered b this m st Month Day. Year
<br /> exec 1 os n in Item 19.
<br /> 2D. Facility Owner or'
<br /> ` T Pr' /Typed Namel Sign e, f D
<br /> Ir Y l L-t S !T�/s
<br /> DO NOT-WRITE BELOW THIS LINE.
<br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS.
<br /> (Generators who submit hazardous waste for.transport out-of-stale,
<br /> DTSC B022A (1/99) produce completed copy of this copy and send to DTSC within 30 days.)
<br /> EPA 8700-22
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