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Department atneoma <br /> State of Callomia-Health and Welfare Agency _ Toxic Substances Control Division <br /> For m�prov d OMB No.2050--0039(Expires 9-30' Sacramento,California <br /> net a�type. (Form desi ned for use on el 2- itch t ewriter). ManifesP� 2. Page 1 Information in the shaded areas <br /> UNIFORM-HAZARDOUS �l Generator's US EPA IDN � Document No. <br /> of is not required by Federal law. <br /> WASTE MANIFEST - / A. State Man test Document Number <br /> 3, Generator's Name and Mailing Address r ` <br /> Ilr E4 grsv, fSHN fj�1�XEIJs,C/ %5.) q% <br /> 1 B. State Generator's ID <br /> I <br /> r <br /> 4. Generator's Phone(,! I f`, /' ' M / <br /> N 5. Transporter 1 Company Name <br /> a. US EPA ID Number C. State Transporter <br /> 's ID <br /> r) F. 2 4 1 7 D. Transporter's Phone <br /> ]. Transporter 2 Company Name <br /> 8, US EPA ID Number E. State Trensportar's ID <br /> m F. Transporter's Phone <br /> mUS EPA ID Number G State Facility's ID <br /> 9. Deaignated-facility Name and Site Address <br /> J I,FyI IF.ti ;> !IOi ' <br /> H FacddY's Phone <br /> 13331 ( ' <br /> PAT111 ..01:, ( 45363 <br /> C 8 3 1 6 6 7 <br /> Z 12. Containers 13. Total 14. I. <br /> ¢ Ouanbry Unit Waste No. <br /> O 11. US DOT Description(Including Proper Shipping Name,Hazard Class.and ID Number) No, Type Wt/Vo <br /> LL <br /> � I State <br /> ¢ a <br /> U <br /> Z G i1t,STi "OIL !.'10.5 COMBl1STIt3LF LI'It 1 EPA/Other <br /> E :F. 12711 r.__ <br /> N State <br /> w R 1/r 1 (." ,,,,.� �/ .". EPA/Other <br /> m A <br /> 't O � State <br /> ' RC. <br /> 0 <br /> a EPA/Other <br /> m <br /> State <br /> y¢ d. <br /> F <br /> w EPA/Omer <br /> U <br /> yK. Handling Codes for Wastes Listed Above <br /> J. Additional Descriptions for Materials Listed Above <br /> Z b <br /> e. <br /> O <br /> a <br /> w c. it. <br /> Z <br /> Z <br /> P: 15. Special Handling Instructions and Additional Information <br /> Z <br /> W <br /> I <br /> F <br /> J r <br /> J <br /> ¢ 16. <br /> U GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping <br /> name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable <br /> LL <br /> international and national government regulations. <br /> m If I am a large quantity generator,I certify that Iha've a program in place to reduce the volume and toxicity of waste generated to the degree I have <br /> ¢ determined to be economically practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to <br /> O me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator. I have made a good <br /> C�. faith effort to minimize my waste generation and select the best waste management method that is av itable me and that I can afford. <br /> U <br /> Printed/Typed Name Signature Month Day Year <br /> Ulu T 17, Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> ZZ A Printed/Typed Name _ Signature Month Dey <br /> N �. <br /> LL S <br /> U P O 1t,. Transporter 2 Acknowledgement of Receipt of Materials <br /> m R Printed/Typed Name Signature Month Day Year <br /> ¢ T <br /> U E <br /> Z <br /> - — 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <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 Primed/Typed Name F Signature Month Day Yeer <br /> DRS 8022.A(1187) / INSTRUCTIONS ON THE BACK <br /> EPA 870D--22 YELLOW: GENERATOR RETAINS -� <br /> (Rev.9"88) Previous editions are obsolete. <br />