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Slate of California—Environmental Prolect�on Agency - <br /> Form Approved OMB No. 50-0039lUrligs 9,.39-99) See Instructions on bac Page 6. Department of Toxic sub}J�n Hees Contr <br /> Please print or type. Forr'hlvesigned for use ortelite(12-p'.4.1/typewriter. Sacramento,callF �sio <br /> / 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded aredin <br /> UNIFORM HAZARb&S is not required by Federal law <br /> WASTE MANIFEST t'ro I of <br /> t i •..5 _ <br /> 3. Generator's Name and Mailidg Address State Manifest Document Number <br /> c`r ( <br /> 1.1..}1.11 :i'r�..•{e:r,c.l �, t� ;��..t .`"� k4� "i <br /> r• B. State Generator's ID <br /> p :..I :.i. ±t C::I_...� <br /> h 4.'GEn�ator's Phone f s) <br /> n � <br /> CV 5. Transporter i Company fume - 6. US EPA ID Number C. State Transporter's ID(Reserved.] <br /> N <br /> ao <br /> O �r D. Transporter', Phone <br /> p f`.' '21427..r;?;7 <br /> tb 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID(Reserved.] <br /> . J F. Transporter's Phone <br /> Q <br /> '0oU 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> r''�t'I1s�'CJO rAST 26""hf "f Gf,F::f;T H Facility's Phone <br /> -A T,I r1 I fu t- !t <br /> Q - <br /> rip pU X11. U$DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total ld. UnitNo. Type Quonti WI/Vol I. Waste Number <br /> f Z }ry_ l �State <br /> r � �`c�'�c�i'tT��+.ai�� ���}�a7�j-c'���.°-i��-'��i-i-�:�{��'7—�"• f `'�. <br /> 00 <br /> E B't(7AI RCRA W-ARDOUS Ytf,a.�1T; !X-RAD(C%-"ABSi)i'if eu) B A {{ <br /> 1 f i 13 EPA/Other <br /> v R "Y J A3i 3r n <br /> NV A c '! sfatc <br /> o T <br /> co O EPA/Otiior-- — <br /> R 4 <br /> LU d. stale <br /> LU <br /> 1— <br /> Z EPA/Other <br /> U <br /> LU - <br /> tn 1. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z NAEF1(3;° i1NOPd. ,5 11 Li- Nk1R <br /> Lu <br /> i i Bi 31f}7:�v-f''kar5+Jl?#IG TA*3 f CSL <br /> d. <br /> J <br /> Z <br /> O 15 d Additional information <br /> Special Handling Instructions and <br /> (.AU i::hPJ' 0-Sf-',F('W'1-,W 4",7 2i l ('J <br /> Z '* SLL TO E?AIL C'�d]ViENTAL RECCiWRY Sfrl�.sACC "' USE POP AFF1Y EOJ)F'h F.NT a E:R WC*2 174,3-E1 0 <br /> = <br /> FATE. <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are full and accurately described above by proper shipping name and are classified,packed, <br /> marked,and lobeled,and are in all respects in proper condition for transport by highway a y rding to applicable international and national powrnment 4egulations. <br /> If I am <br /> a large quantity generator,I certify that I have a program in place to reduce th vat me and toxicity of waste generated to the degree I have determined to be economically <br /> V1 <br /> practicable and that I have selected the racficable method of treatment,storage,or d'pas currently available to me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a Sino I quantify generator,I have mode a good fa' f rt to minimize m waste generation and select the best waste management method that is <br /> d available to me and that I can afford. _ .. <br /> 0} Printed/Typed Name Sig }� rt�r' ,1��r/r p / Month Days Year r <br /> w T 17, rp oder 1 Acknow eclement of Receipt of Materials <br /> R rintSi nature / Month Day. Year <br /> A Ped/T ped Name 9 t <br /> N ! d <br /> LU P <br /> LL 8 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> Q R Printed/Typed Name Signature Month Day Year <br /> T <br /> LU E <br /> R <br /> V19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> I 20. FacilityOwner or Operator Certification of recei t of hazardous materials covered 6 This manifest except as noted in Item 19,-",' <br /> Printed T ed Nome /` .." Signature ,� <br /> Month Day Year <br /> DO NOT-WRITE BELOW THIS LINE. <br /> DTSC 8022A 11/99) <br /> Green: TRANSPORTER RETAINS <br /> EPA 8700-22 <br />