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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9.30-99) See Instructions on back o' - 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitcf Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> is not required by Federal law. <br /> WASTE MANIFEST G A p • J '� 1 'f of a <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number /� 31 2 <br /> Q&-K - 2AM$1'-, T�r9 rf 4-4 L <br /> o t?e.. 34Y_ 60& <br /> +n 14 <br /> s 7c'c t: 77G�J G F� 9 B. State Generator's ID <br /> LO A. Generator's Phone(.7G 9) y(C <br /> CV 5. Transporter I Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> L <br /> 00 <br /> O D. Transporter's Phone <br /> 0 n5S A.+ t.2c5 !M� t«/ FS <br /> c <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's TD[Reserved.] <br /> J <br /> J F. Transporter's Phone <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> � Q <br /> r GiGc3Z3`�'' <br /> JJy'1� LJ, f l'7 4 'STlzi tC% H. F-cility's Phone <br /> � � LSI +L t>��Et f,f L� `��-' ! 3 C. A D a y C: ! `t � - > r <br /> Q <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number 12. Containers 13. Total 14. Unit <br /> U p� ( g p pp gr ) No. Type Quantity Wt/Vol I. Waste Number <br /> A s / `L•A/h ev,r4 13 Z.g I- <br /> 3 <br /> Slate <br /> 3 GV IU 1 C!Gf 3 + � 3 j "' EPA/Other <br /> E <br /> mN W 5'! —OL F�A r:z M 13L 1 � 1 (-�:.s t J $� IC 1 D• 5, State-� <br /> w E X ( i'C ;2 C�L --!" t�13 i r C.L r1 "-C=5 �, �j t.�11 J G el EPA/Other <br /> 'tet R } / t-- ! � <br /> C14 A r 17'1- <br /> State <br /> 0T A 1 5 L _ <br /> w O <br /> R EPA/Other <br /> C, <br /> I i irC r7 1 <br /> F- d'W�Stt ear-t4G,St✓E G.tCd.. i 7f�LiC:tC. /MJI���T1 State J <br /> E <br /> v - },�3. 1•''; tit if EPA/Other <br /> W ` I - 3 C, r <br /> NJ. Addition/a� Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> 0- *P 1 ) ja. b. <br /> ,�4 <br /> i1f�/�lP'� °Y C �' •O t i }y' (s <br /> LU <br /> !L} aG�a(c 11x5 Falb ' C. d. <br /> Z .1.0 15. pecial Handling Instructions and kdditional Information L,.I�•A iG'•- tryl2 ���� �Far {� <br /> Z 2y H,Z. Fe"E1Zvf Nt � Ca �-f;t`)C C'�,N,9L rA vi r4.r. A4, tFNj AL �5f vj� t �- 13 � O <br /> W <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by per 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 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 /> d 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 /> Ce available to me and that I can afford. <br /> O <br /> } Printed/Typed Name Signature Month Day Year <br /> U <br /> w T 17. Trans orter 1 Acknowledgement of Receipt of Materials , <br /> w p Printed/Typed NameSignatu t Month Day Years ` <br /> W u <br /> P -J✓J%i/-1 �•r r d / r / 1, 0 ` <br /> D 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> 0 T Printed/Typed Name signature Month Day Year <br /> tL E <br /> N <br /> Q R <br /> U 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 /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 0 (1/99) <br /> EPA 87700-0-22 Yellow: GENERATOR RETAINS <br />