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S ote oP7difornioVlinvironmental Protection Agency <br /> iroro,A.r .veal OMB No.2050-0039(Expires 9-30-99) See Instructions on back of,e 6. Department of Toxic Substances Control <br /> Please•' int,*type. Form-designed for use on elite(12-pitch)r 'er. Sacramento,California <br /> 1. Generator's US EPA ID No, Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS F f $ `: ,' y is not required by Federal law. <br /> WASTE MANIFEST t• _ of <br /> 3 Generator's Name and Mailing Address A. State Manifest Document Number ,. <br /> to -=yl£ttP-.A '4I��' <br /> & f A*-,5 LINE ria. <br /> � dE .t #< tst� U pg B. State Generator's ID <br /> LO 4. Generator's Phone( w i @ J v 10%r. :; '1F :s ;�kid K <br /> LO 5. Transporter 1 Company Name 6. US EPA ID Number - C. State Transporter's ID[Reserved.] <br /> 00 <br /> O [�ta�K �VI&D-`O3 ''�?SI. TEM1. aY �j D '�+ 0 9 4 ,fix' 2 fS 5 D. Transporter's Phone - <br /> N <br /> 7. Transporter 2 Company <br /> s� Pame 8. US EPA ID Number E. State Transporter's ID[Reserved.]' <br /> JQ F. Transporter's Phone <br /> ^-V 9 Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility s ID, <br /> 4 T0�11s,�„'tom [jiU9VIRI HYt�A.s:. e <br /> . a:: 21 Skin .��� t A u1 0 2 S 4 � r, '" H. Facility's Phone <br /> U11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number] 12. Containers 13. Total 14. Unit <br /> '+ No. Type Quantity Wt/vol I. Waste Number <br /> Z <br /> MA-MA Re—MM-16 <br /> State <br /> fi I'M P 2 j <br /> G EPA/Other <br /> o N b. <br /> State <br /> m <br /> m E <br /> 4 R - - EPA/Other <br /> v A <br /> o T C. <br /> State <br /> w O <br /> R EPA/Other <br /> H d. State <br /> Z <br /> U EPA/Other <br /> W <br /> N J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> Z <br /> O a. b. <br /> a <br /> N <br /> W <br /> C. d. <br /> a <br /> oa , ; <br /> 15 Special Handling Instructions and Additional Information u' <aio ':rana):e�s�F >'..r.. €w , <br /> Q <br /> Z <br /> LU <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantiy 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 economically <br /> a practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health <br /> N 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 waste management method that is <br /> C' available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature Month Day Year <br /> Z ..N.,..-..... 7 <br /> W <br /> C9 T 17. Trans offer 1 Acknowledgement of Receipt of Materials <br /> R <br /> w A Printed/Typed Name Signature Month Day Year <br /> Uj <br /> U- 0 18 Transporter 2 Acknowledgement of Receipt of Materials 4 <br /> TPrinted/Typed Name Signature Month Day Year <br /> W E <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> A <br /> 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 /> 0' 2289 DO NOT WRITE BELOW THIS LINE. <br /> DTSC 0 (1/99) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br /> s <br />