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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 of -nge 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch) iter. Sacramento,California <br /> 1. venerator's US EPA ID No. Manifest Document No 2 Page i Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST <br /> of <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> 77 J <br /> 1'w <br /> B. State Generator's ID <br /> In 4. Generator's Phone ( [ <br /> I <br /> cV 5. Transporter 1 Company Name 6 US EPA ID Number C. State Transporter's ID[Reserved.) <br /> LO <br /> OP <br /> O D. Transporter's Phone <br /> O <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> �aV.1 J <br /> Q F. Transporter's Phone <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> 'f <br /> H. Facility's Phone <br /> h � <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> , Type Quantity Wt/Vol I. Waste Number <br /> Z a. State <br /> S <br /> H <br /> 3 G EPA/Other <br /> o N b stare <br /> OD <br /> ao E EPA/Other <br /> v R <br /> CN <br /> A c Stare <br /> o T <br /> op O <br /> R EPA/Other <br /> LU d State <br /> 1— <br /> Z <br /> W <br /> U EPA/Other <br /> LU <br /> J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> a. b. <br /> w <br /> a c. d <br /> J <br /> Q <br /> Z 15. Special Handling Instructions and Additional Information <br /> 0 <br /> t-- <br /> a <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 /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and notionaPgovernment regulations <br /> V <br /> J 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 /> CL practicable and that I have selected the racticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healt <br /> N h <br /> and the environment;OR,if I am a sma I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> cj' available to me and that I can afford <br /> O <br /> } Printed/Typed Name Signature Month Day Year <br /> U <br /> Z <br /> w T 17. Transporter I Acknowledgement of Receipt of Materials <br /> A <br /> LU I Printed/Typed Name Signature Month Day Year <br /> LU N <br /> LU S <br /> u_ p 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> A <br /> T Printed/Typed Name Signature Month Day Year <br /> UJ E <br /> N R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> A <br /> C <br /> I <br /> L <br /> 20. Facility Owner or Operator Certification of receipt of hazardous moteriols covered by this manifest except as noted in Item 19 <br /> T <br /> Printed/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A (1/99) Yellow: GENERATOR RETAINS <br /> EPA 8700-22 <br />