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Slate of California—Environmental Protection Agency <br /> form Approved OMB No.2050-0039(Expires 9-30.99) See In SIr UcF10n5 On back OF —age 6. Department of Toxic Substances Control <br /> Pli print or type. form designed for use on stile(IDpilch 'rifer. Sacramento,California <br /> UNIFORM HAZARDOUS I. Generator's US EPA ID No Manifest Document No. 2. Page 1 I Information in the shaded areas <br /> �iG of I of required by Federal law <br /> WASTE MANIFEST If I <br /> 3. Generator's Name and Mailing Address _ A. Slate Manifest Document Number <br /> 21806840 U `- 0 <br /> /(T 117- ( 4 B. State Generator's ID <br /> f- JJ, <br /> vi a_ Generator's Phone( " .I I s.��= ( i- I �� f i-i i . '(`�C <br /> n <br /> N 5, Transporter I Company Nome 6. US EPA ID Number C. Stale Transpoder's ID[Reserved.] <br /> h <br /> m <br /> d nMf'illr-n,N V!,,i[_c'r 4V),A ti-(f_ A I. F) Il O 8 9 yT jl 7 8 D. Tnnsportah Phone (:^ ._ ibr <br /> 0 <br /> OP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporhr's ID[Reserved] <br /> F. Transporter's Phone <br /> 00 V 9'!Dif gh0lad'Fbd1)iy$dine`ahy;Srl6Alldrg3('. 10. US EPA ID Number G. SIc *5NyjLID0 0 1 •t Q << tf t <br /> 00, I�lVCiiISANIC, '.:'!i 5ii1Fi7 <.; A �. ✓7 () 1] 1 ti 4 $ 1 ft M. Focilfly;s P�tgq�i�$1 1 <br /> 000i <br /> Q 11. US DOT Description)including Proper Shipping Name,Hazard Class,and ID Number) No C°nlainers 13. Tocol 1 d. Unit <br /> N V No. Type Quantity Wt/Vol I. Wash Number <br /> _Zis, NON-PCNA HAI At-DOU.` WASTE LIQL110 Stole 11111 <br /> 1 t`,Ji�Y LYi�Trl1 j it U <br /> !IT G r _ E9A/98ar <br /> N E b. _ State <br /> o N <br /> m E EPA/Other <br /> v R <br /> N <br /> v A state <br /> o T <br /> 00 EPA/Other <br /> R <br /> w d. State <br /> wZ <br /> EPA/Other <br /> V <br /> w <br /> J. Additional Descriptions kr Malarials Listed Above K. Noodling Codas for Wmfm Listed Above <br /> Z <br /> o OILY WATUR a. of b. <br /> w <br /> r. d. <br /> a <br /> Z15. Special Handling Instructions and Additional Information <br /> Z CMEI((if: Pirl:)NC 2U13-6672f857 <br /> w <br /> x <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurti,described above by proper shipping name and are classified,pocked, <br /> Vmarked,and labeled,and are In all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> J If I am a large quart, 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 econornim <br /> ha <br /> Lythe <br /> cticable and that I ve selected the precabavailable mixes <br /> ' <br /> le method of treatment,storage,or disposal currently availae to me which mini the present and future threat to human -u t� <br /> - dad dee in rironmeoY OR,if I am to a smalldi <br /> quantity generator,I have made a good faith effort minimize my waste goneration and select the best waste management method that',' ` <br /> K available to me and that I can afford. <br /> y Primed/TypadVRlasna ..-i- 'I F,•' �7/ Signaly��1�T t .. - / �.- 'nrh/ Doy Year <br /> w T 17. Trans rte,I Ackaawled ement of Receipt of,Materials ! <br /> R <br /> w k Printed/Typed Na me Signature �' Month 'Oay'l YPar-� <br /> (7 <br /> w P - <br /> u- B 1 B. Transporter 2 Acknowledgement of Receipt of Materials <br /> Month Day Year <br /> R Printed/Typed Name Signature <br /> w E <br /> "n R <br /> V19, Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> l 20. FacilityOwneror armor Cartificati of receipt o hazardous materials covered b Oenoffset e e 1 as ted in it.. 19. <br /> T Printed/Typed fJbme /� Signature r� .,/ ff�on , ) oy/ C7 X <br /> /( / <br /> DO NOT WRITE BELO HIS LINE. <br /> DISC 8022A(1/99) - <br /> EPA 8700-22 <br />