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State of Callfomic-Envisonmentol Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of pr 6. Department of Toxic substances Control <br /> Please print or type. Form designed for use on elile(12-pitch)ypl`ser. Sacramento,California <br /> w <br /> Q UNIFORM HAZARDOUS Generators US EPA ID No. Manifest Document No. 2. Page 7 is not required <br /> a the shaded areas <br /> not required by Federal low. <br /> WASTE MANIFEST of : <br /> 3. Generator's Name and Mailing Address A. Store Manifest Document Number .. .. <br /> B. Stab Generators ID <br /> A <br /> A <br /> A. Generators Phone 1 I <br /> 1 <br /> H 5. Transporter 1 Company Name m <br /> 6. US EPA ID Number C. Slate Tnsporter's ID Reserved.] <br /> D. Tmnsparlm's Phone <br /> �= <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transp.rNs,%ID[Reserved.] <br /> E Transporters Phone <br /> J 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> H. Facility's Phone <br /> ad <br /> ,. <br /> N. Containers 73. Total Id. Unit <br /> Q <br /> V 11. US DOT Descriplien lincluding Proper Shipping Nome,Fiozvrd Class,and ID Number) No. Type Ouanriry weNol 1. Wash Number <br /> a. .. . .. <br /> Stale <br /> Z <br /> ' EPA/Other <br /> 3 G <br /> E State <br /> o N b. <br /> m E EPA/Other 1 <br /> e R <br /> A State <br /> �ro T <br /> m Q EPA/Other <br /> R <br /> z stat¢ <br /> �w EPA/Other <br /> v <br /> _a <br /> 1. Additional DeMaterial.riptions forMaterial.Listed Above K. Handling Codes for Wastes Above <br /> Z 6b. <br /> a , <br /> h <br /> w d. <br /> Q I <br /> "Wo 15. Special Handling Instructions and Additional Information <br /> F _.. _ ... <br /> Q I <br /> Z <br /> w <br /> S <br /> r <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shiMin,name and am classified,packed, <br /> Lmarked,and labeled,and are in all respects in proper condition for transport by highway according to opplicable international and national government regulations. <br /> If I am a large quantity r <br /> generator,I certify that I have a program in pface to reduce the volume and toxicity of waste generated to the degree I have determined to be econamicolly <br /> Npr Iicable and that 1 brave selected the practicable method of treatment,storage, disposal currently available ro me which minimizes the present and future threat to human health <br /> and the environment;OR,if I am a small quantity gen raror,I have made o good kith effort to minimae my waste generation and select the best waste management method that is <br /> a' available to me and that I can afford. <br /> `y Printed/Typed Noma Signature Month Day Year <br /> U <br /> ..Z <br /> w T 17, Trans rrer 1 Acknowlodgement of Receipt of Materials <br /> R <br /> -y A Printed/Typed Name Signature Month Doy Year <br /> w <br /> S <br /> wi 0 I8. Transporter 2 Acknowledgement of Receipt of Materials <br /> T Printed/Typed Name SlgnaNre Month Doy Year <br /> w E <br /> Q R <br /> p 19. Discrepancy Indication Space <br /> F <br /> _ A <br /> C <br /> I. <br /> 20. Facility Owner or rotor Certification of receipt of hazardous materials covered by this manifest. t as noted in Item 19. <br /> i T Pamw/Typed Name Signalure Month Day Year <br /> Y <br /> seeL jL�, ���r ��� /� DO NOT WRITE BELOW THIS LINE. <br /> /0SC - /-��� <br /> DTSC 8022A 11/99) Yellow: GENERATOR RETAINS <br />