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Slaty of California-{1ealth and wailers Agency See Instructions on Back of Page 6 Uepartmeni of Haaith <br /> l IC <br /> Fotm Approved OMS No 2050--p019(Expires B 30 BI) 7 rorlc Subslancna Control 111v1s1 <br /> and Front of Page T Se rementnl Celifl,m <br /> Pteaae prlhl or type Forrn designed for use on elite(12 pitch typewriter) <br /> UNIFORM HAZARDOUS t Generator a US TEPA ID No Mnndent 2 r'na- Inrnrrnnrin 1 in the shaded areas <br /> Derurrinnt No of I9 nit rngnirrA by Federal law <br /> WASTE MANIFEST <br /> 3 Generaa r a ame and Marling Address / A State nileat Document Number <br /> 0.4 —9-01an-m— <br /> f <br /> A/R� P ,tri d r i r, .Il /!' C 7I�l i!c!• Jy/ fv 'j1B State Generelor a In''�) Q \r8iv�rPhon « <br /> 5 Transporter r Company N me 8 US EPA ID Number C Slate transporter s 1p <br /> to <br /> J:WD Transporter a[, n o I <br /> n <br /> T transporter 7 cr-Unpany ams y US EPA ID Number OF E SIRIe Transport rY <br /> cc <br /> 0 I I I I I I I I I I F Transporter e l hone <br /> CD <br /> r 9 Desig+raled Fnrdrly Name and Site Address 10 US EPA ID Number G Male Fardilfya��I�{��ID,}}}CCC <br /> Prteksnt ��� <br /> t. Inc. H Rc Ilty� nor hoI����� <br /> 251 Parr PIvd. <br /> Rio"# a 9 <br /> CJ?Z h1.3� — <br /> Q 12 Containers 11 Tolil II <br /> i 1 US DOT Denrplion (Including Proper Shipping Name Hazard Cinns and IT) <br /> ry Quantify Unit Waste No <br /> n <br />��4 No lypo __ wtlVof Stals <br /> + �►elste Irmptp Storage Tank S12 <br /> G <br /> E ... EP f f]iher <br /> C.i 3 N H - <br />(1)a p b Slate <br /> T EPA/Other <br /> It O - <br /> � R c � State <br /> o _ <br /> Co EPA!Other <br /> W d State <br /> r <br /> Z <br /> U EPA!Other <br /> WLJ Additional Descriptions for Material*Listed A K Handling Codes 1101 Wrrgtea Listed Above <br /> z a b <br /> QtY'll ._ Empty 3talcage TAttk (s) � (21 <br /> 'Tank (s) have been tnerted I ss c <br /> Dr to P�! LOE0 Cola �.'1l�lII�I E�'i <br /> z <br /> 0 <br /> 15 Special Handling Instructions end Additional Information <br /> a <br /> KeeP sw++p from sources of Ignition. Allorajy veru hordbint s when worikitiq around <br /> U&SaTa rs 24 Hri Contaot Name L �4� � S _ & P1hor1Y7J 42L4 77 a 7,5 S <br /> J <br /> U t9 <br /> GENERATOR S CERTIFICATION I hereby declare that the contents of this consignment ere fully and accurately described above by proper shopping name <br /> and are classified pecked marked and labeled and ere In all respects In proper condition for transport by hlghwny according to applicable International and <br /> CIL. national govermmnnt regulations <br /> If I am s large quantity generator I certify that I have a program In place 110 reduce the volume and laxlclly of wnite genraled In Ihr degree I have determined <br /> 0 to be economically practicable and that I have @elected the practicable method of treatment storage or disposal carr tly available In ms which minimizes the <br /> >_ <br /> present and future threat to human health and the environment OR if I am a small quantity generator I have mado a good faith eflnrl In minimize my waste <br /> CJ generation and 9elecl the best waste management method that Is available to me end that I can afford <br /> Afanrh Day Saar <br /> LLI PrilttedlTyped Name <br /> f ll Si9net�re / ! <br /> LU 1 J / l r i ( ri <br /> W T 17 Transporter 1 Acknowledgement of Receipt of Materials If <br /> F1 I- <br /> ZMonth Day 1 <br /> 4 Print yped Name gig ear <br /> I.L. 9 <br /> 0 p <br /> W O 16 ranapor r 2 Acknowledgement of Ree ipt o elerlals <br /> �< R Printed/Typed Month Da Year <br /> T YPed Name Signature Y <br /> E <br /> Z_ <br /> IB Discrepancy Indication Space Cry <br /> A i <br /> I <br /> r ) <br /> ,. L <br /> T20 Facility Owner or Opnretor Ce rb8t n of receipt of hazardous materials Covera y this mendeat exceyf as nota¢m item 19 — <br /> 1 / ! �- Month Day eqr <br /> y PrlMed/Typed Name Signator <br /> ( 44I <br /> DIES 8022 A Do Not Write Below This line <br /> �! T <br /> Er A 8700--22 <br /> (Rev a 89)Previous edlttons nre obsolete <br /> �rh 111,1 rr f1o1< r�� � r" niFPATf?f tivlfHl�f 'tr r�+1 <br />