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State of California-TEnvironmental PrPlectio .Agency <br /> Forrn Approved OMB No.2050'`-0039(ExpifBs 9-30-94 "{ <br /> f lease riot or ) r See Instructions On b page 6. <br /> p type. Form designed/or use on elite 1 Department of Toxic Substances Cc <br /> typewriter. <br /> UNIFORM HAZARDOUS en ator's u EPA ID 3 Sacramento,California <br /> ,1 j5 n Manifest Document No. 2. Page 1 Information in the shaded areas <br /> C WASTE MANIFEST V G ! is not required by Federal law. <br /> 3>-.G�g�erator's Notne an Mailin Addless �giWrl 91 -T Q of <br /> �} <br /> ,n _s1911,� .�'rC;9s�✓ fes oacun 'N m <br /> "a, <br /> St'Sr <br /> C&toi� 1D a s : 4 a <br /> to 4. Generator's Phone ( ✓� 61 <br /> 5. Transporter 1 Company Name ` ! * �* r <br /> 6. US EPA ID Number c5 s <br /> yWON <br /> -' 7. Transporter 2 Company Name A6 xt <br /> U 8. US EPA ID Number <br /> t <br /> -9 Designated Facili N me and Site Ad re 10. US EPA ID Number ' <br /> N Q' h�'✓TJ1G �'"N�'/.�'�°v1//3)Fiy�"�� 7f�'�,•vC�l���c�'"' � ��„r � �� ' ,`�J <br /> eta 9,/3d, <br /> A <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12• Containers 13. ie:a! 14. Unit <br /> Z n/� No. T Quantity Wt/Vol f 1A/q <br /> 'N AI `.Q Q� Nels. <br /> f a E00 , <br /> N <br /> co <br /> R9 A ae�c<�a� T4-1 t I (rr>v vt�Faa,�.��,� �(�p � siare <br /> E o A ©� � f� , (, -4 EPA/c � <br /> 1= <br /> I 00 `ti/`/ �'J:�C�/!.S <br /> W EP R N 3cic; t '111 �Pt A�wtck�c�tnk►sr�� �G?. a <br /> F• ,Uj <br /> Other <br /> U <br /> N”C/r RC -�' f�Il� :r 1�4D �G 6 3��r / . 1�Y $tatC'' r t <br /> I` y� <br /> H L ` �J� /�� �r'w /i� /+ L! }J�T � EPA <br /> Z J Additional Do ' tions for Mote <br /> # Y, a 4 .' fit s1°rl6tt R fF+ Stec Above <br /> 7- <br /> O0 <br /> 15. Special Handling Instructions and dddronal I fo ma}�9n �•s w,. <br /> t- .w► i�J;.+�.�-C� y I�.�� ��cr _/� JW <br /> Uj <br /> -+ 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> J � <br /> Vpacked,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> I <br /> _± If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have a determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future <br /> in threat to human health and the environment;OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> X waste management method that is available to me and that I can afford. <br /> 0 Printe /Typed Name Signature <br /> Month Day Year <br /> U <br /> Z T 17. transporter 1 Acknowledgement of Rec t of Materials ' <br /> NPrinted Name ...•" Signature <br /> 'J/ / -^ Month•_ Day Year <br /> W P x`'11 ,'` � I /'t; r' .r"c / <br /> LLJ O 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> U_ TO n Printed/Typed Name Si afore Month Day Year <br /> E <br /> LU 19. Discrepancy Indication Space <br /> N <br /> U F <br /> A <br /> Z C <br /> 1 <br /> L <br /> 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> T Printed/Typed Name Signature <br /> Y Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (12/91) <br /> EPA 8700-22 <br /> Yellow: GENERATOR RETAINS <br />