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Stare of California—Ervironnsxslal Protect.Agency <br /> Form Approved OMB No.2050-0039(Expires 9-3096) See Instructions on back of page 6. Depod n«n of Taxk Substances Control <br /> Pease prim or". Form designed for use on elite(12pirch)sypawriM. <br /> Sacramento.California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 I Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST /" G / f. n > !� of <br /> Q J. Gerseralor's Nome and Mailing Address D� I'fI� D a d 1 N I A. State Manifest Document Number' <br /> n 14'L( a.� C 11rJ'IWSot's-!K� t, <br /> -1 B. Stare Generator's ID <br /> N mta � -ebb <br /> 4. Gera 's Phare ��� :!L?I i l� V C� �� G) e— <br /> S. Transporter 1 Company Name 6. US EPA(D Number C. Stole Transporer's ID <br /> m <br /> - lD. Transporter i Pham <br /> '- � � `= - d00-7' 2—N64' <br /> 7. Transporter 2 Company Nome 8. US EPA ID Number <br /> a V E. State Transpore/s ID <br /> 4 <br /> 11. Transpoden's Pham <br /> Z 9. Designated Facility Nome and Site Address 10. US EPA ID Number O. State Facility's ID <br /> A 111 1) 19 19 14 5 12 17 10 <br /> .I 7 H. FaAW,Phaw <br /> 11 d <br /> -1 7 (1 562-598-5577 <br /> 11. US DOT Description(including Proper Shi Name,Hazard Class,and ID Number) 12. Ganlanen 13. Total 14. Unit <br /> Z PNe^(i "roShipping <br /> = No. T l7u WI/Vel I. Waste Number <br /> F a. <br /> 11 Stag <br /> EEPA/00w <br /> mN Is. State E <br /> y R EPA/0", <br /> b{ A <br /> a T C. 5 ate <br /> O <br /> as R EPA/Other <br /> W <br /> Z d. <br /> W FiE <br /> U <br /> OJ. Additional Descriptions for Materials Listed Above K. Halling Cedes for Wastes listed Above <br /> 1 a. Is. <br /> N <br /> w 1i <br /> K <br /> Q <br /> <. d. <br /> Z <br /> O 15. Special Handling Instructions and Additional Information <br /> Z <br /> Z <br /> W <br /> S <br /> F <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 arc classified, <br /> U <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and retionwl government regulations. <br /> —+ If I am a large quo"generator. I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> y <br /> economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and furore <br /> W threat to human health and the environment,OR, 8 I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> W wase management method that is available to me and that 1 can afford. <br /> O Printed/Typed Name S <br /> L l � f <br /> WA 17. Tram r 1 Acknowled of Remit of Materials <br /> (� L Printed/T Nome / Signature <br /> W P <br /> W 0 18. TM r 2 Aclursowledgmem of Receipt of Materials <br /> W F Pnhrled/Typed Name SignaNre <br /> O Month Day Year <br /> V) 19. Discrepancy Indication Space <br /> U F <br /> A <br /> Z C <br /> 1 <br /> L <br /> 1 20. Fadlity Owner or Operator Cerlificat orn of receat of hazardous materials covered by this manifest eccea need in Item 19. <br /> T Primed/Typed Nam SigneNro <br /> r Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DISC 9022A (1/95) Blue: G' 'ATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> EPA 8700-22 `/ To: P.`�x 400, Sacramento. CA 95812-0400 <br />