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State of.Cplifornic--Environmental Protection Agency <br /> Form A,)p'oved•OMB No.2050-003UExpires 9-30-94) See Instructions on back 9e 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on eNe(12-pit writer. Sacramento,California <br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> Ci/� Q 1 3 �S 9 is not required by Federal law. .. <br /> WASTE MANIFEST 6 . Cl, of <br /> ,$ Generatpr' Nome and Mai b Addr s A State Manifest Dacument N mb`r <br /> l"i�}i'r/fi!"/�% • B State:Genera(ot's ID " ?'', t" <br /> CN 4. Generator's Phone ( ?3 ""` <br /> p 5. Transporter 1 Company Name 6. US EPA ID Number C Staff Trapsporfgr'5 1D - <br /> °° �� � ��, Ptia� � '� <br /> la: 7 <br /> w.+ r' <br /> f J <br /> J 7. Transporter 2 Company Name 8. US EPA ID Number Tam 4"! <br />:+ U � v <br /> Q 9. Designated Facility Name and Site Address 10. US EPA ID Number Fa�tbty's D 'Ff��llh'L � <br /> _d <br /> U 12. Containers 13. Total 14. Unit" <br /> {—: 11. US DOT Description mciudin Proper Shipping Name,Hazard Class,and ID Number' <br /> �Z p ( 9 P PP 9 1 No. Type Quantity Wt/Vol 1 Wo0e,Num15er. <br /> State <br /> Ale��i�' .�����'i� .�` �!:�,�'"�� �fit/„6 /� ,f <br /> �3 G �/tf'f:`TYe�'�'v f'/ �l'V: .`1 !/1� 1.3f G�t'� G C l>> C)C`'� �/ EPAMA <br /> 04 E J <br /> 00 N b Store <br /> 00 E r <br /> `t <br /> C4 R EPA/Clther ' <br /> 6 A <br /> 0 <br /> 0 T c stat® <br /> 00 <br /> R EPA/Other <br /> w <br /> d State <br /> LU <br /> t <br /> U EPA/06 <br /> LU <br /> N <br /> J. Additional Descriptions for Materials+�fisted Above ` y{ ` K'Handling Codes for Wastes Listed Above " <br /> b. <br /> wfC + " GSA <br /> stJF;t eta c. d. <br /> Q m t'• <br /> - <br /> Zf Af &V 15 ia(Ha dlin I i l I rmafion C�rAr <br /> y r , 7 <br /> r /r #�f�NC � 1+ "Il?) <br /> a I <br /> Z <br /> Uj <br /> /.�:�f 1i,�' �='.�'?'^:�,�"��/ E" CASE�:,�,.!F,�r�' ��r?ia',j,•!,/ ,,�r/„te�`�,�,��'r.! <br /> J 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 /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable federal,state and international laws. <br /> U <br /> !' <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 determined to be <br /> 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 /> d threat to human health and the environment;OR, if 1 am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best <br /> N <br /> waste management method that is available to me and that I can afford. <br /> 0 Printed/Typed Name 1 tt A Signature J fj/� Month_ rpay dear r <br /> U !! <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU R _ r Month Day Year <br /> A Printed/Typed Name 11 Signature q <br /> LU v <br /> 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> LU R Month Day Year <br /> T Printed/Typed Name Signature <br /> LL <br /> 0 R <br /> LU <br /> 19. Discrepancy Indication Space <br /> Q F <br /> U A <br /> Z C <br /> I <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 Month Day Year <br /> Y <br /> - 1 1 1 iI I <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 0 (12/91) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br /> tri <br />