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.olifornia—Environmental Protection Agency I f <br /> wed OMB No.2050-0039(Expires 9-34 99] See Instructions on back o --age 6. Department of Toxic Substances Control <br /> type, form designed for use on elite(12-pitcl Sacramento,California <br /> - l�erator's US EPA ID No. Manifest Document N 2. �-:ge ' <br /> Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST t J Iew 1. L,^ <br /> 3. Generator's Name and Mailing Address _ - A. State Manifest Document Numbed <br /> u - _ B. State Generator's ID <br /> O <br /> 4. Generator's Phone <br /> n <br /> N 5. Transporter-1 Company Name -. 6. US EPA ID Number C. State Transporters LD[Reserved.] <br /> h <br /> °D .! 3 D. Tronipofler's Phone <br /> O <br /> O <br /> a0 7. Transporter 2 Company Name 8. US EPA ID Number E. Slate Transporters ID[Reserved.[ <br /> J F. Transporter's Phone <br /> `.V <br /> 9. Designated Facility Name and Site Address 10, US EPA ID Number G. State Facility's 1D <br /> ; Z H. Facility's'Phone r <br /> .JF f O <br /> u_ <br /> 12. Containers 13. Total 14, Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. Tye Quantity Wt/vol 1. Waste Number <br /> NZ a. <br /> State , <br /> EPA/Other <br /> G <br /> o N b. State <br /> co <br /> oG E EPA/Other <br /> 4 R <br /> c� <br /> q A C. Slate <br /> o T <br /> o <br /> EPA/Other <br /> cle State <br /> LU d. <br /> w EPA/Other <br /> V <br /> LU <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes For Wastes Listed Above <br /> LU r <br /> w <br /> ac <br /> C. d. <br /> a <br /> Z 15. Special Handling instructions and Additional Information ! g <br /> 0 <br /> w w <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 are classified,packed, <br /> Vmarked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> �_ <br /> If I am°large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to tfte degree 1 have determined to be ec <br /> o <br /> nomicayy <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently ovatlole to me which minimizes the present and future threot to human heahh <br /> N and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> available to me and Thal I can afford. <br /> OPrinted/Typed Name Signoturc,✓i' Month Day Year <br /> cu T 17. Trans+orter 1 Acknowleclemeni of Receipt-of Materials .R• <br /> a' Prinled/Typed Name Signature Month Day Year <br /> ::E 5 <br /> P <br /> sa. R 18. Transporter 2 Acknowledgement of Recei i of Materials <br /> R Printed/Typed Name Signature Month cloy Year <br /> T <br /> N E <br /> � R <br /> U 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20. Fac0i Owner or Operator Certification of receipt of hezordous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature Month Day Yeor <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />