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State of California—Ewironma{ttaI Protection Agency <br /> FofmAppro�'"*No.2050+x0039(Expiris 9-30-99) See Instructions on back of p 6. Department of Toxic Substances Conttrr%l <br /> RlBose Pith*or type: form desigried for usejon elitd f 12-pitch)iA_sriter. <br /> Sacramento,California <br /> a, <br /> 'e""" ' 1. Generator's US EPA ID No. Manifest Document No. 2, Page 1 Information in the shaded areas <br /> UNIFORM HAZ I)OUS _ f aw <br /> is required by Feal l <br /> WASTE MA FEST (( �} ,° C� 1 1011 <br /> } 3. Gen o nd M Q ddress 5tnt,* <br /> 4 <br /> 4. Generotor's Phone ( ) 1 <br /> eV' 5. Transporter 1 Company Name 6. US EPA ID Number State Tic <br /> 00 <br /> _ <br /> Transpo-rter s f , <br /> AA <br /> ccr <br /> O N <br /> _ ... <br /> ! 7. Tra spotter 2�paN 8. US EPA ID Number State Tran pci iVQ •\ 1 �.1 (/ 7ranspnrfe sF)or 6ftr <br /> 9. si noted Facility Name and Site Address 10. VS EPA ID Number StatcyFac Idy>IL <br /> tj <br /> A o 31;r �I �` - <br /> V Q12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(ipluncluding Proper Shipping Nome,Hazard Class,and ID Number) No. Type -Quantity Wt/vol V✓ ste Number <br /> !JZ a. No r! -f4�1 AZ><19 (;Ur, L1jA? S�^►T <br /> o E b. <br /> aO E P <br /> N R DK ENVIRONMENTAL FACILITY IN LOS x <br /> v A x <br /> o T ANGELES, ,:. <br /> o APPROPRIATE PERMITS TO RECEIVE YOUR <br /> R <br /> Ce WASIE SIRFAM AS QUALIFIED 01-IR EPA, <br /> -- - -- <br /> Lu <br /> d. NUMBER IS CAT080033681 �' <br /> Z _. <br /> '1F V <br /> A/(,!w, <br /> W <br /> ,,c. Abases K Ha ��in-^3 C"1 ,F^�W�3t Tisted A4�ave _ <br /> O. <br /> r r <br /> uj <br /> 15. Special Handling Instructions and Ad tonal Information <br /> Z, <br /> LLj <br /> Y f_.�)NTACT T(_.,1l-M0fif&AN 90- it 7 z) f R ' I <br /> 16. GENERATOR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, <br /> Umarked,and label and pr�all r� t in proper condition for transport by highway according to applicable international and nation�a-I go`ernmentt r lotions. <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 economically <br /> practicable and that I have selected the practicable method of treatment,sIQtage,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 /> available to me and that I can afford. <br /> 0 <br /> e y Printail/Typ�d Name Signoturp,''-_X 6onth0Day �;;Xeor <br /> w T17. Transporter 1 Acknowledgement of Receipt of Materials <br /> W A Pripte /Tzped N ti Signaturb `�Qay ,'(eat. <br /> >~ �I cvfl; t l rr Z ,I tt%+-1 i` r,J <br /> wP <br /> sa 0 18. Transporter 2 Acknowledgement of Receipt of Materials .� <br /> Month Dai <br /> TR Pr ni a Typed Narr�t Year <br /> S t _p° --- ^'-s <br /> Lu E <br /> 4. <br /> / /J' - <br /> V19. Discrepancy Indication'Space <br /> F <br /> A t.._. <br /> C <br /> I <br /> L <br /> I 20. Faci' Owner r Operator Certification of receipt of hazardous materials covered this manifest except as tad In It '19. <br /> T <br /> Prin e y ed Na Signal / M nth Day / Year <br /> V <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS— <br /> (Generators <br /> 22A(1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> DTSC 80 <br /> EPA 87022A produce completed cop of this copy and send to DTSC within 30 days.) <br />