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Z <br />3 <br />Form Approved OMB No. 2050--0039 (Expires 9-3091) <br />of :.• �. ...� rc�.� � v .• ... .... � .n•. r nA e.n.w:r..l <br />5114 Front Of E'ao- 7 Toxic Substances Control Division <br />Sacramento. Cnifornla <br />DHS 8022 A 0188) Do Not Write Below This Lige <br />EPA 8700-22 White: TSDF SEN'^: 11`115 COPY TO DOHS WITHIN 30 DAYS <br />(Rev. 988) Previous editions ate obsolete. - ,1 <br />Tc F.C. i._: 315' Sorromentc CA 95812 <br />UNIFORM HAZARDOUS <br />I.\/hxetci a US EPA ISD Ngo. Manliest <br />mac. Page <br />Information In the shaded areas <br />WASTE MANIFEST <br />^% p I I�IC 4 a 1 n <br />.� a <br />of <br />snot required by Federal few <br />3. GenertWirs Name and Me ingp� rose <br />1Jevan�S % ci1l wICYn <br />A. State Manifest Document Number <br />-Kfyj <br />-1,713 '%;� L S CD (TS <br />S. State Oenxetor's ID <br />1� <br />a. Generator's Phone ( ) STQCp� a Pl ICA�J <br />6. Transporter 1 Company Name e. US EPA ID umber <br />C. Stale Transporter'a ID <br />` <br />��f,AK Y �(/ 1) 17 19 131 <br />D. reneporler'e Ph <br />7. Transporter 2 Compo y Name S. US EPA ID Number <br />E. Stats Iransporter's ID <br />F. 7ranspc"oea Phbrro <br />9. Designated Facility Nome end Site dd ass -�� 10. US EPA 10 Number <br />C t:g ^ r1���s1 �..� <br />G. Slate Facility's ID <br />7 c� 01 kfi t <br />�w�sTE <br />'Cr 3`a"3y <br />H. acilNY's Phon <br />e <br />( n d 6 1.� <br />.. - <br />2-01 <br />(Including Prr ippin9 Name, Hazard Class, and ID Number) <br />11. US DOT Description (Inope <br />12. ContaInan <br />Na. Type <br />13. Total <br />Quantity- <br />14. <br />unit <br />W nit <br />I. <br />Weals No. <br />a_ <br />state <br />E <br />N <br />T <br />hon 4r—e-44 R <br />' <br />EPA/OMx <br />E <br />b. <br />State <br />R <br />A <br />T <br />EPA/Other <br />O <br />fl <br />c. <br />slate <br />EPA/Other <br />d. <br />State <br />EPA/Other <br />J. Additional Descriptions IM Materials Listed Above <br />K. Heading Codes for Wanes <br />Listed Above <br />b <br />a <br />Lego <br />. <br />16. Special Handling Instructions and Additional Information <br />1 <br />Poe � <br />( F � 1l-4Lc. /��d� 2 3 Z� <br />7-4 4(L. moker`jrTarl tri 5c C <br />16. <br />GENERATOR'S CERTIFICATION: I hereby declare that the covens of this con slgnme arm fully end acture»ly dasmibsd above by proper shipping memo <br />and are classNbd, pecked, marked, and labeled, and aro In se respects In proper condition for transport by highway according to applicable Inlemnional and <br />national government regulations. <br />If 1 am a large quantity geaeretor, 1 certify that I have s program In place to reduce the volume and toxicity of weals generated to the degree I have determined <br />to be economically practicable and that I have selected the practicable method of treatment, storage, W disposal currently available to me which minimizes the <br />present and future threat to human heath and the environment; OR, If I am s smell quantity generator. I have made a good faith effort to minimus my waste <br />generation and select the beat waste management method that is available to me and that I can afford. <br />Prim p /Typed Name - � <br />Signe - Month Vey Yoe <br />•ice V -er`t <br />\_. ---- <br />T <br />17. Transporter 1 Ackeowle emam of Receipt of Materials <br />R <br />A <br />Pd�Type ams net re \ _ Mon Do <br />S1,44:! <br />14 ( L <br />rMateriele <br />P <br />O <br />19. Transporter 2 Ac nowledgemerd n Receipt if <br />T <br />Printedf Typed Name <br />6t9 lure Month Day Yew <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />1 <br />I <br />20. Facility Owner or operator CMNleelion of receipt of ha:erdoua materials oovxetl by this menliset except es moist In Mem lg. <br />y <br />Pfinled?ed NeyjI� <br />12 <br />SignnuroDay Year <br />DHS 8022 A 0188) Do Not Write Below This Lige <br />EPA 8700-22 White: TSDF SEN'^: 11`115 COPY TO DOHS WITHIN 30 DAYS <br />(Rev. 988) Previous editions ate obsolete. - ,1 <br />Tc F.C. i._: 315' Sorromentc CA 95812 <br />