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State of California—Environmental Protection Agency. SEB IITSt�UCtiCRS OTL bQCIC O: :9B [1. Department of Toxic Substances Control
<br /> Form App ed OMB No.2050-0039-(Expires 9-30-991 1 - -, - " - - -- :- Sacrdmento,California
<br /> Please V6inre-dorm designed for use:on elite 1 f 2 pitch} r{ler• 2 Pae 1 Information in the shaded areas_
<br /> 1. enerator's US EPA ID No. Manifest Document g is not required by Federal law.
<br /> UNIFORM HAZARDOUS
<br /> WASTE. MANIFEST b ' :� "�_; " `S of
<br /> eTptpr s'N]�me an Mail i g Address f 7 V,f` State-Montfest Document Num6er� y�
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<br /> O15. Special Handling Instructions'and Additional information _ - _ -
<br /> a WE 'R�►I EC``t" t1 .CLO_RfL i � RGE-i X hF' - N E.
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<br /> 1'tS. GENERATOR'S CERTIFICATION: Thereby dedaFe that the contents of this consignment are Fully and accurately described above by proper shipping name and are classified'packed,
<br /> Q marked,and labeledrynd.are in all respects in proper condition far transport by highway according to applicable international and national government regulations. ,'
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<br /> IF I dML0 forge quo generator,I certify that I have a program in place to'reduca the.volume and toxicity of waste generated to the degree I have determined'fo 6e economically
<br /> 'practicable and th6t I have selected the-practicable method of treatment,storage,or disposal currently available to me which minimises th'e present and future tf reaYto-hutian'heaitfr
<br /> t and the environment;OR,if I am a small gu, I ly'generator,I'hwe made a good faith effort,to minimize m'y'waste generation and select the best waste management method That is
<br /> available to me.and thal I can afford. "s
<br /> O Month Day Year
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<br /> f u1 T - 17. Trans otter 1 Acknowled ement of Receipt of Materials
<br /> i oC .h n Typed Name Sig ures nth : iRay�. �ear.�
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<br /> ��A- 18. Transporter 2 Acknowled emeht of Receipt of Materials .-' '_`
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<br /> U ,19. Discrepancy kndicahon Spoce r -
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<br /> 20. Fa ill Owner or O .rotor Cert,ficalion of receipt of hazardous materials cove s ani st ext t as n Item 19..
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<br /> re Day Year
<br /> T � r � Si atu Month
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<br /> DO NOT WRITE BELOW THIS -LINE.
<br /> TDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS..-
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<br /> (Generators who submit hazardous waste for transport out-of-stole,
<br /> 4' DT5C 8022A{1/99) produce completed copy of this copy and send to DTSG within 30 days.)
<br /> ', EPA E17110-22
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