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State al California—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-3099) <br />Please print or type. Foran designed for use on elite (12 -pi Ies,,.,pewrihzr. <br />de. <br />See Instructions on back r\ J78e 6. Department of Toxic Substances Control <br />Sacramento, California <br />)TSC 8022A (4/971 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow; T5DF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state <br />_produce completed copy of this copy and send t< DT5C within 3F d ys.l <br />1 Generators US EPA ID No. Manifest Document No. <br />2. Page 1 <br />Information in the shaded areas <br />UNIFORM HAZARDOUS <br />is no required by Federal low. <br />WASTE MANIFEST <br />) <br />r n Q ({ 6 ! <br />of <br />l <br />3. Gemrar's Name Mailing toand linAddress <br />A. State Manifest Document Number R <br />EkV,I..I T�, . <br />5707210 <br />/2177/ 6r. 7ti SfflCj <br />B. State Generator's ID <br />Moch,v+ % �� Fs3 �� <br />4. Generator's Phone IZOr ):57,V-7,0_3 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's 10 <br />� <br />) >7�„ 9 G O 0 <br />D. Transporter's Phor f,2Oq 97,2--9900 <br />-/ <br />/Zrf' r G. / Y <br />L d / t1 i1 <br />7. Tmmporrer 2 Company Name R. US EPA ID Number <br />E. State Transporter's ID <br />I . Transporter's Phone <br />9. Designated Fadlity Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />H. Facility'. Pho <br />J J /, <br />rate <br />_ ✓1 5 <br />IUS <br />900/j 7 O <br />11. DOT Descri tion m udin Pro Shipping Nome, Hazard Class, and ID Number <br />P ( Per R f <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Val <br />1. Waste Number <br />No. <br />Type <br />)PP <br />�j9'1 <br />State <br />EPA/Othm <br />Nb, <br />t <br />State. <br />E <br />R <br />EPA/Olhar <br />T <br />C. <br />State <br />O <br />R <br />EDA/Other <br />d. <br />Stab <br />EPA/Other <br />J. Additional Descriptions for Material. Uses Above <br />K. Handling Codes far Wastes <br />listed Above <br />c. <br />d. <br />15. Special Handling Instructions and Additional Information _ _ _c.7 _, E %'. <br />'_-:. J <br />1-7 <br />.. <br />16.'GENERATOR';'t TIFICATION: I hereby declare that the contents 6f this<gt igrent are fully and accurately described above by proper ship ingn a and are classified, packed, <br />marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and nationts government regulations. <br />If I am a large quantiq generator, I certify that I have a pro ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be e<onomico11y <br />future human heolM <br />Practicable and that have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and threat ft <br />and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation one[ select the best waste management method that is <br />available to an. and that I can afford. -- <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />T <br />17. Tran rror 1 ACknow ed ement of Recei t of Materials r' <br />R <br />R <br />Pripted/Typed Name <br />Signature j^ � / <br />MonthDay Year <br />R <br />IS. Turns tier 2 Acknowi'ad emenl o{ Recei t of Materials L' <br />T <br />Prin /Typed Name - <br />Signahsfe <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />L <br />I <br />fa<ili Owner or O erarer Certificolion of recai t of hazardous materials <br />covered this mani6at ex<e t as noted in Item 19. <br />T <br />rP�,d%fyped Name <br />SignaNre <br />Montt _ Day Yea115' <br />3 j <br />)TSC 8022A (4/971 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Yellow; T5DF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state <br />_produce completed copy of this copy and send t< DT5C within 3F d ys.l <br />