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State of California—Enviranmmal Protection Agency <br />Form Approved OMB No. 2050-0039(Eapirm 9-30-99) <br />PIsw ryw. <br />dh sl' (12 'khl sYPe <br />See Instructions on back of pL,,A.' -Ell( Departmentn`Department of a^ sCb �Ta adtrol <br />e pintForm design. ru»an �M -Pr ...mr. - <br />1. Oeneroror's US EPA ID No. Manifest Document No. 2. Page I <br />1 <br />Information in shaded areas <br />UNIFORM HAZARDOUS <br />a not r 'rad Fdxal lay. <br />eg <br />WASTE MANIFEST 9 <br />of <br />3. Gain ar%Name and Mailing Addnu <br />asJle Q CO,.peJ a. a..f/CJ�/'] <br />A. Sete Manifest Dacumwt Number 22918176' w ^ ,r �y <br />L I9 VX Il / i6� <br />8. Slate Gerrerator i ID <br />e^EE <br />y0"v —� "`�tPg`w <br />palClA.eat, e*- 91/4 2 / <br />d. Generator's Phone (nt, 16 <br />14 <br />6. U8 EPA 10 Number <br />C. SYGN iransparter's ID Rnory .) <br />5. Tromporter 1 Company Name r <br />ne _' <br />V Y <br />D. Transporters PhoEn <br />f T <br />7. TT•ran .11 '- B. US EPA ID Number <br />Company_ NNo�e,,�,� <br />' E. Stam transporter's ID IR,S;e^_ed.) <br />� ��/2 k-� <br />Xct6l) ! �i�1�J lG{JE�� �� 7Jt1� O l� <br />! <br />p <br />F. r any a er, Phan. Q <br />9.Designated!Facility Name and Sire Address 10. US EPA 10 Numbw <br />i IV <br />G. State Facility'Designated! <br />cAro8o013352. <br />la <br />H. Faeaily's Pham <br />-nil eA <br />70W N • <br />�, E6ee CA 90277• Z999� O 1' <br />3Jo-S 3�- ?14c7 <br />11. US DOT Description Iissduding Pngr Shipping Noma, H/azard Class, and ID Number) <br />12. Containers <br />No. <br />T <br />13, Total <br />Quantity <br />IA. Unit <br />Wt/Vol <br />I. Wage Number <br />A1".&e,6& ., �er/0 /7 05 <br />a. j t D <br />Slate <br />EPA/Olh <br />l`,ss,I GIS• <br />/TT L &-Zr— <br />3,P- <br />o <br />04061, <br />G <br />- <br />N <br />to <br />/ , A <br />b. WAS eYT!•1e.wfitZ bY7.[�F71,1, n.O.�tY <br />SroN 3J <br />EPA/OtMr <br />A <br />3 ` v/v 19 3 <br />Say.DOW <br />O <br />EPA/Other <br />R <br />d. <br />Stan <br />j <br />I <br />_.. <br />a,. <br />EPA/Other <br />! <br />1. Additional Desaripgone fan Marer'ials ❑steed Abovs <br />Pref <br />K. Handling Com for Was»s b. A ve <br />b. <br />Ct �..K w �ls.�ia/—En4;lz�r <br />P <br />61 QI <br />i <br />S�k o.�.Nodl.el —7 rv'1 isoµ,. a. <br />c. d. <br />15. Special Hatt ing Imnuaiom and Additipfiral 16harancifife, <br />ZY/t,111 Serio -T4fa� 0l1�/ <br />T eAp <br />16. GENERATOR'S CEOIFICATION: I hi dealare that theconem..11his conig mare Fullyand accurately descriabove bed ablay prope"hippmg name and are <Ia 18d, packed, <br />for trarsport by highway according ro applicable International and national in, <br />in ngubfiom. <br />I a <br />procondition <br />marked, and Iobeld, and ore in all reper respects <br />II I am a larg quontitY generator, I ini tho I have prog9ram in place to reduce the rakers and tonicity f wets generated ro the d Brae I have determined b M economical)r <br />that I hove »)ectad the method of treatment, Garage, dispo t currently ..'V661. m m. which m zea the pr wt aed future threat to human h mii <br />prbcti,xi and practicable <br />and the environments OR, if I am a small quantity generator, 1 hove mode a good faith effort to minimi: <br />y ovate gwaradontnl d salts the beth wpsle manogomwt method Bial is <br />available to mead that can afFwd. <br />Jrimi d/Typed Namei Li(111gU/ <br />wily <br />ature <br />Men(tLF 2Yea <br />O <br />s 7 <br />77. Tranainifft,) Aloo-lodipmemi of Rini F hitt ials <br />R <br />i <br />Printd/Typed Name <br />Signature <br />Year <br />lb Day Y <br />c S <br />k <br />0 <br />18. Tri.in,arna2Acknowlediftement aF Rwsi Iof Ma iota <br />i j <br />Prin TypdN me J� <br />Sie66� <br />n <br />> E <br />R <br />M <br />/ <br />j19. <br />A <br />Diepo cation Space <br />if ,ir>x4 TCO 21�/gts6 <br />{ <br />C: <br />! <br />20. Fti Owner or Operator Certification of receipt of hazardous materials covered this m <br />orad in Item 19. <br />Prinmd/TYped No <br />month Day Year <br />o <br />T <br />If <br />.S <br />DTSC SOPA (1/991 <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />White- TSDF SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br />Tm P.O. Box 3000, Sacramento, CA 95812 <br />T - <br />m'— n.s• 1' F -_. <br />