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Stare of Colif.mis Emi emmrnnal Protection Agency <br /> Farm Appmrd OMB NR.2050-0039(Expire 930-94) �� SOO IeftPVgtlOnf 00 bOCIE f 790 6. Department of erste Substances Control <br /> Please Print or type. Fenn designed for use on.tiro(12-*-h T vm4 r. Saoamenb,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in be shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal low. -.F <br /> WASTE MANIFEST q of <br /> � 3. Generator's Name and M1,1-11 I'dd.ev A. State Mdn fe"5l- ' � <br /> ^ ST(�CkTpl•1 rA 91206 i <br /> 4. Gene rotor's frholse (�flcJ) 46't-4"h�' 1T iN: ART SMi TH H H s �� `I Q� 2� ���.;3� "71 ;3 — <br /> 6. US EPA ID Number a Transporter's ID �2 <br /> S. Transporter 1 Company Name <br /> nsporter's phone <br /> 7 Transporter 2 Company Name 8. US EPA ID Number a Transporter's M <br /> osporrer's Phone - - <br /> 9 Designated Facility Name and Site Address 10. US EPA ID Number Facility's ID <br /> F'lEGl;R r� ,i rat 71 41 T I al <br /> WE'WF1Py f I �+ - <br /> („) ;i 12. Containers 13. Total 14, Unit <br /> Z 11. US DOT Description(including Proper Skipping Name, Hazard Class,and ID Number) No Type Quantity Wt of este Nomber <br /> _ - - <br /> i!I L ! /Other <br /> GIll Ill 4 rJ M V <br /> s+ E <br /> N Is. <br /> E a/cher _ <br /> R <br /> A < <br /> T `' J <br /> R A;atm <br /> � R <br /> Z d <br /> VA(O!her <br /> Zal De Nions f r Mal s Lb+ad Above <br /> 2 1n , 1h. <br /> 1 <br /> N <br /> J <br /> Q <br /> 0 15. SpecialHandlingInstructionsadAdditionalInformation 41G7AR f+F'OP R F'4nTfa f1VIE V-117,411`16, GLOVE; AND bIIGGL.F'S. <br /> Ila PEEP OUT OF WaT;,RWH I` <br /> Z CMFPh�1,!,".y c'HQNF idi1 <br /> W <br /> H <br /> .� 16. GENERATOR'S CERTIFICATION: I hereby declare that the content of the consignment are fully and accurately described above 6y proper shipping name and are classified, <br /> packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to opplicable federal,stale and international laws. <br /> U <br /> � <br /> If I am o large quantity generator, I certify that I have a program in place b reduce the volume and toxicity of waste generated to the degree I haw determined to be <br /> economically predicable and that I have selected the practicable method of treatment,storage,or disposal currently available b me which minimizes the present and fvNre <br /> Nthreat to human heath and the environment,OR, 'rf a small quantity gerwrabq I have made a good faith effort he minimae my waste generation and select the best <br /> waste management method that is available b me and th can afford. <br /> � Month Day <br /> O Printed/Typed Name J " Signature - '/ i`11 i,cf+.y 1 ! "iT <br /> Yaor <br /> WT 17. Transporter I Acknowledgement of Recei t of Materials <br /> IsMonth Day Year <br /> O H P+innd/Typed Name �,� Signature <br /> s <br /> 222 r <br /> 0 18. T s c no ed .most si 1 el a s <br /> W i Primed/typed Nome Signature Month Day Vwr, <br /> O e <br /> W 19, Discrepancy Indication Space <br /> Q F <br /> V A <br /> Z I <br /> _ 1 <br /> L <br /> l 20. Facili Owner or raterr Certification of recei t of hazardous materials<owrad b this manifest except as soled in Item 19. <br /> T Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (]/92) <br /> Yellow: GENERATOR RETAINS <br /> EPA 8]00-12 <br />