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tPlState of Califomia—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-3&94) See Instructions on back of Depoamern of swic Substnnces[.noel <br /> ease print or type. Form designed for use on elbe(12ylAch)typawn Sacramento,Colilormo <br /> AZRDOUS I. Generator's US EPA ID No. Manifest Document Na. 2. Page 1 Information in the shaded area <br /> UNIFORM HAs <br /> ' is not required by Federal law. <br /> WASTE MANIFEST1916101011 l � S 6 / of <br /> 3. Gerserator s Name//and Ma�jiling Address A. State Mardfest Document Number <br /> tbib ,r <br /> V, C>,7!-//([KK^^_r de. �01 79 <br /> 95118111 <br /> lookq" B. State Generator's ID <br /> 4. Generator's Phone ( ) -211 <br /> co <br /> h 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transports/s ID <br /> D. Tramp. 's P <br /> J/�T /2 Compano hkSy <br /> l nc. L 4i <br /> 7. Transporter 2 Company Name 8. US EPA D Number E. State Trizifsponfors10 <br /> Q� <br /> U F. Transporter's Phone <br /> 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> si 6 l <br /> Am <br /> hofe, H. Faciliyis Phone <br /> D S O 00 <br /> 12. Containers 13. Tocol 14, Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) No. 7 Type Quantity Wt/Vol I. Waite Number <br /> /la -?o&w of "fie gate zI <br /> GL1// S/ / D D EPA/Other <br /> E �/ <br /> —6 Ale <br /> m N b. Safe <br /> E <br /> R EPA/Other <br /> o T < stare <br /> O <br /> R EPA/Other <br /> Z d. Sae <br /> w <br /> V — <br /> �'EPA(Chhcr, <br /> I <br /> '.{ Additional D scnpfions for Materials listed Aboyc 1 �.= K. Handl nq Codm for Wastos Listed Above <br /> 49, <br /> d. <br /> Z _ .--- -- <br /> O 15. Special Handling Instructions and Additional Information <br /> F <br /> H <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 are classified, <br /> packed,marked,and labeled,and are in all respech in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <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 future <br /> threat to human heahh and the environments;OR, 'd I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that I can afford. <br /> Printed/Typed Nome Signature Month Day Year <br /> r O <br /> U T 17. Transporter 1 Acknowled ement of Rttei t of ostrich, <br /> R <br /> A Pinsed/T ped Name Signa re Mont/ Day yees- <br /> 18. Transporter 22ed mrmVZT Receipt of Materials <br /> , Printed/Typed Nome Sigrwhrre Momh Day Year <br /> R <br /> W 19. Discrepancy Indication Space <br /> N <br /> Q F <br /> A <br /> Z <br /> E <br /> f20. Facili Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19. <br /> T Printed/Typed Name - Signoture Month Day Year <br /> v <br /> DO NOT WRITE BELOW THIS LINE. <br /> 'DTSC 8022A (9/93) Blue: GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> To: P.O. Box 400, Sacramento, CA 95812-0400 <br /> EPA 870D-22 <br />