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{ <br /> sta .1CalYwnio--EaaronmentalProtection Agency See Instructions on back of <br /> scot Approved OMB No.2050-0039(Expires 9-30-99) - F X <br /> sc6195 Depadment of Ta do S--_ 1€mvaf- <br /> eam print or type. Foran designed lar ose on elite(12-pitch) r. Saaomenro,C t <br /> -- - --_.. _--_— 1. Generatols US EPA ID No. Manifest Document No. 2. Page 1 I.Formati..in the shades <br /> UNIFORM HAZARDOUS is^al required by Federal <br /> WASTE MANIFEST C A 9 8 1 6 3 0 4 1 1 8 2 0 9 7 er 1 <br /> 3. Generatee,Name and Mailing Address {oiehkan f t DoCum Pnt Number <br /> PAc1c F�[S. <br /> 22 <br /> PO 130% 5095, ROM #3F7D00 e Stare ,nto�,ID <br /> A_ Genemto/s Phone <br /> USAN 112A99DN CA 94583 (9l5 )n3- gg66 I <br /> � Op & b. US EPA ID Number e srn. 1 anspormrslDlRas�j748' <br /> rD - - <br /> m <br /> REMEDIATION, IW-. <br /> CAD 0 6 3 5 4 7 9 9 6 ° Tr°n p "P"'- (408)268-1196 <br /> 7. Transpor er 2 Company Name 8. US EPA ID Number E.Stine T pqr> •llj fle a <br /> r <br /> F kapsp <br /> Q <br /> 9. Desjgnated Fanhy Nome and SJe Address 10. US EPA ID Nomber G Slain, s 1D <br /> _._, rr,....�.._-,__:U SEE ,46,7 �R�tt-e7y <br /> -I- /3 a x J 1 1 1 1 1 1 <br /> ate <br /> O , t(4-154 a24 <br /> 11. US DOT Description(including Proper Shipping Name,Hamrd Class,and ID Numbed 12. Containers 13. Total 1d. Un t _f <br /> Na. F T Quantity Wt/Vol I Waste Number <br /> Z State <br /> _ IASTE.PLA88ABLE LIQUIDS, 11.0.3-PSOLI118, 019M), 3881993 PGII <br /> RQ I00181SIGf(128) V o ( T T D S� G EPA 0her D001( <br /> o <br /> State <br /> N b' <br /> R. <br /> ..•A• c - _ 'Stale <br /> %ex T <br /> m O <br /> R. E{tYi[pjFer <br /> d. <br /> W <br /> C, FPAtr <br /> pITi- <br /> b 75. Special Handling tno,e,Iicn,and Additionalnmforafio. Rte^ ^ NOW11"6,5 :QENNRGEIICT RESPONSE CALL (800) 947-7701rT V` Y <br /> r <br /> _r 16. GENERATOR'S CERTIFICATION: I here6y declare that the conlenh of this consignment are fully and accurately descd a <br /> ribebove by proper shipping name and are classiRed,packed, <br /> marked,and labeled,and are in all respects in proper condition for transport by highway according m applicants international and rm mmu government regulations. <br /> If I am a large q by generator,I edify that 1 have pr ram in piece to reduce the vol me and toxicity of waste g erated ro the degree I have determined to be economical <br /> h practicable sad that I Imva elected the practicable me"oI treatment,storage,w disposal currently available to me which minimizes the present and tenure threat to human health <br /> and the environment OR,if 1 am a small quantity generator,I have made a good faith egad to minimize my waste generation and select the best waste management method that is <br /> awikbfe to and that I wit afford. <br /> Printed/Typed Narm�e� Signature i� Month Day <br /> Year <br /> 11-21 1 153101 Z <br /> W T 17. Transporter 1 AclumMedgeommi of Recei 1 of Materials <br /> � E <br /> Pr,i�ypad Nama Signatore Mundt Day Year <br /> OE 18. Trans rter 2 Acknowled emeriti of Receipt of Materials Year <br /> TPrinted/Typed Name Signature Month Day <br /> " E <br /> E p�� <br /> 19. Discrepancy Indication Space } 7 <br /> F ! GipEW}� Us <br /> Z A Ha }- �2 •bgI;au&e �- _ �r'mT as t9. �' vr`t Envlrbnm.Gn Fc.1, ync <br /> � f10� 42XO`�'u)tQr <br /> E 1 Oti vt 1,' i(A 1Jt39 1 a oz <br /> Me 20. Fodh or remn,Certificationtfreesirstf6csto..materials covered Itis manifest ax as noted' 9. <br /> T printed NameSignaMe Day Year <br /> T n- 1 <br /> r rmJop, DO NOT WRITE BELOW THIS LIN <br /> SC 8022A 11/991 White: TSDF SENDS_THIS COPY TO DTSC WITHIN 30 DAYS. <br /> A 8700-22 To: P.O. Box 3000, Sacramento, CA- 95812 <br /> r <br />