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Sloie of Colibr9ia—EmironmoNol Protection Agency See Instructions On bock Of P `e 6. Department cf Toxic Substances Cont, <br /> Form Approved OMB No.2050-00391Expires 9-30-991 Sacramento,Calibrnia <br /> Please print or type. Form designed for use on elite(72-pitch)t ler. <br /> 1. neratoi s US EPA ID No, Manifest Document No. 2. Page I Information in dos shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST p ! of ' <br /> 3. Generator's Nome and Moiling Address A. Stare Manifest Document Number yq se ,pe rs <br /> AA 41ii.iile,.4.A) MAl slis.•1 N tAi. F.4 aA 111"U1s: 2ii 9L/. <br /> 8503 <br /> T,iif 4Y:f N IS rfHM, :R.V1a. Li i(X K 1 C1114. (,A Ultt?.isf.� B. State Generator's ID <br /> ur) a. Gnerotor's Phone( <br /> r S Transporter Name Company Ne b. US EPA ID Number C, 5mte Trampanei s ID(RerervedJ <br /> m $ +Ysrs D. Tranaporeir's Phone <br /> d -;it's 1-IsvivithiuriQill i1 Sef vasa <br /> m8. US EPA ID Number E. Slab Trvnsporte/s ID(Reserved.] <br /> ]. Trorssporter 2 Cemporry Name <br /> F. Transporter's Phone <br /> Q <br /> V 9. Deaigmted F«ifiry Naam and sire Address 70. U5 EPA ID Number G Sbte Faci Fry's ID <br /> -1 % - . ls_,. rt i. ,...a <br /> Z - •V 1-. J+7 {ft 1-4 .. H. Facility',Phone <br /> CCO CA 9W71 <br /> Q 1 l US DOT Description lindudirtg Proper Shipping Nome,Hazard Class,and ID Numbed 12. Cantoinara 13, Total IA, Unit <br /> V No. T Quantity Wt/Vol I. Waste Number <br /> Z isSante <br /> EPA/O' <br /> c E b sap <br /> o N <br /> CD E EPA/011ier <br /> e R <br /> A Sbe <br /> o T <br /> m O EPA/Other <br /> R <br /> w d. State <br /> Z <br /> Z <br /> a+ <br /> v EPA/ah.. <br /> w <br /> H 1. A"Mor al Descriptions for Op1erialsyLiged Above K. Handling Cadet far Wastes U.W Above <br /> a <br /> N <br /> ac <br /> « c. d. <br /> 0 15. Special Nordling Instructions and Additional Information <br /> P: <br /> Z _ .. <br /> w r�rl1 k#.�41`'+P1C{At.. r"p 54t . '_1C• k 1r 'hj.. ,, .� b`i.ttffii <br /> x <br /> 16. GENERATOR'S CERTIFICATION- herby dadare that the consents of this consig mens are fully and accurate�s.d cribd vbova byproper ship <br /> oruig mons and are classified,packed. <br /> Vmarked,and labeled,and are in all respects in proper condition ter transport by highway according to applicable international and national government regulations. <br /> If I am a 1.19 q e fgenerator,I certify that I hove a program in place to reduce the volume and toxicityof waste generated to the degree I have determined a be ono c fly <br /> a practicable and that I lam er <br /> elected thepoctimble method of treatment,storage,or disposal currently available to me which minimizes the present and Future threat to human heabh <br /> XP and he environment;OR,if I a small quantity generator,I hove made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> QC available to me and that Iran afford. <br /> O <br /> >. <br /> Firm 1 d/Typed Name -} signature Month Day Year <br /> Z esu. ;�, v'� <br /> W 1 19. T,.n,porte,1 f Rei of Materials <br /> ac Printed/Typwf me Signature None, Day Y. <br /> W <br /> B 18. Transporter 2 Acknowhedgenner,of Receipt of Materials <br /> O T Priomcf/Typed Name Signature Month Day Year <br /> w E <br /> H R <br /> Q 19. Diu pa <br /> V raponsy Indication Space <br /> Z F <br /> — A <br /> C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification of reset 1 of hazardous materials covered by this manifest.ace 1 as noted in Inm 19. <br /> T Printed/Typed Name Signature month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DT5C 8022A 11/991 <br /> EPA 8900-22 <br />