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EPSON <br /> . . 1:, Al <br /> Slate of Cahlornla-Health and Wlfare Agency See Instructions o ck of Pape 6 De anm•nt of Neahhil l! <br /> Form Approved OMB No.4050--0099 Expires D-N) and Front Ont 0, 7 Toab BubsUno•a Dontrol DN4 <br /> .Please print or type. (Form designed for use on eflfe(I4-pltch typerniNr). Sscramonto,Calllor <br /> UNIFORM HAZARDOUS 1 1. Generator'&US EPA tD No. Manifest 2 P&P*/' antonnallon In the shaded mu <br /> WASTE MANIFEST 0 6 / 3 Z 6 ZD2 Znt / <br /> of Is not required by Federal low. <br /> S. Generator's Name and Meiling Address A State M <br /> f/ an ea Do • N m�Ir , <br /> .FVb ERN p.4c/Plc Tic�pNs�.er�IrieN �+ t <br /> 'f O/ .r snort r e. Slat*GenaratoYa JD <br /> .�!?GRM�A(rV %'S3iRN/A <br /> E. Trarep;artar i Company Name 6. US EP umber p' C. State' ID <br /> N <br /> M R CAN E,vV - Will C Q p D. 7r&neponer�Pnone <br /> m 7. Tnmporter 2 Company Name e. US EPA ID Number E. St*te'Traneponer'a ID - <br /> F.Transponer's-Phare <br /> Go <br /> D. Designated Facility Nameand ile Address 10. US EPA ID Number 9. State Facility's to <br /> f1i`!ER/C,A/tN� EMC-N/T-�JCORP. 0 I <br /> MO 8'SS aN 11 �Or/D N. Facility's Phone <br /> v = g0 SB / 474 - q 6 <br /> 12. Containers 13. Total t,. 1. <br /> L 11. US DOT Description(including Proper Shipping Name,Hazard Claes,and tD Number) Quantity Unit Waele No. <br /> J <br /> Type Wt/Vol <br /> No. <br /> U a V111RE jPE71?01E111j 94SE0 Sf//L o/EJ-E4 Stets 6 <br /> = G <br /> 100 N E 0fZ1Ff1?N/ EU,64T." W417E oNL p $ D 6 D P i�0iv <br /> 3 E D. State <br /> N R <br /> A <br /> m T EPA/Other <br /> N O <br /> � R c State <br /> fi <br /> m <br /> EPA/Other <br /> Cr <br /> d. State <br /> U EPA/Other <br /> W <br /> v, J- Additional Descnptiona for Materiels Listed Above K. Handling Codes for Wastes Listed Above <br /> biESF1 FaEl AAT sgNO y SOIL (� b. <br /> ad <br /> W <br /> Q C. tl. <br /> y # /176 <br /> F 15. Special Handling instructions and Additional information <br /> 2 <br /> USE PICtj rFC7 vE cZ f rf//!✓C- w HEN N�/✓�'��%'� <br /> J <br /> J <br /> Q <br /> J GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully ana r; o y roper shipping name <br /> J sntl ere c!seee!ied,pecked.-arketl.and labeled,end are in all respects in proper condition for trans; <br /> ia:unaticnal and <br /> national government regulations. kk..���� 44pp����((�1 <br /> Cr If I em a large quantity generator,I certify that 1 have a program in place to reduce the volume and toxicity ofNARgener$ej9QQe degree I have determined <br /> p to be economically practicable and that I have selected the practicable method of treatment,storage,�oartdTiDs(pyosfyaHl ecdu�rrdeanbtly/aavIa'ilable to me which minimizes the <br /> > present end future threat to human health add the environment;OR,if I am a small quantity gene r(T V 1;1\V IV IVI GIV�r'1 Lh letfdrA 1pTnlnimize my waste <br /> p generation and select the beat waste management method that is available to me and that I can d�if}brTl ��V V�V�GLV /'1L rl —A 1 M <br /> Z <br /> W Printed/Typed Name Sign aPERMITMonth Day Veer <br /> ff <br /> w � Q, 2. <br /> WT 1T. Transporter 1 Acknowledge nl of Receipt of Materials <br /> R <br /> A Printed/Typed Name <br /> C Signature Month Day Peer <br /> w O 1S. Transporter 2 Acknowledgement of Receipt of Materials <br /> UR Printed/Typetl Name Signature Month Day Yee; <br /> E <br /> Z_ <br /> 16. Discrepancy Indication Space C i <br /> I V: <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item tg. <br /> T <br /> y I Printed/ ed Name /+ / Sig-alure,p Month Day Yea, <br /> 0 r /li !-r/(1( re /► C <br /> DNS 8022 A(1/66) Do Not Write Belo his Line <br /> EPA BTOD-22 <br /> (RevWhite: TSDF SENDS THIS COPY TO DOHS WITHIN 30 DA <br /> . 70 Previous etl;ligna are obenlele. <br /> To: P.O. Box 3000, Sacramento, CA 95812 <br />