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11/21/2003 14:35 2093394287 FLYING J PAGE 03 <br /> 51 of California—Environmental Protection Agency — See <br /> F Approved OMB No.2050-0039(Expires 9.30.99) Sea Instructions on back a page b. D.parfmSa ofToxic Substances Control <br /> PI a print ar type. Form des%gnad for use on elite(12-pdchl typewriter. Sacramento,Gplifornia <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS I is not required by Federal law. <br /> WASTE MANIFEST ! 4 I °f <br /> 3. Generators Name and Mailing Address A. Slate Manii'mi Documsnf Number <br /> � r� , .,t� .� rh+�, r+ t.,�, 22782861 <br /> ( 4 !t, ` 7/ r... 1.//, ^ 0. Siete Generator's ID <br /> LC 4, Generator's Phone(A')-f <br /> 5. Transporter 1 Company Name 6. US EPA ID Number C. Skstf TransportePs 1D{Resaned.I <br /> 4 / D. Transporter's Phone if • ,�r7 <br /> 7. T I <br /> 4nsporier 2 Company Name 8. U5 EPA ID Number E. State Transporter's I -1 <br /> F, traasporler's Phone <br /> 9 Design Facility Name an."its Address 10 US EPA ID Number G. State Fxi Iyfy's ID <br /> H. Foci 's Phone <br /> 15-1 <br /> V s <br /> 12. Car loinars 13. Total IA. Unit <br /> 11, US DOT Description(including Proper Shipping Name,Hozord Class,and ID Number) No Ty Quantity Wt/vol I. Wath Number <br /> �f <br /> E stale <br /> b. <br /> N <br /> E EPA/Other <br /> R <br /> A c Stara <br /> T <br /> O EPAJOther <br /> R <br /> Slate <br /> d. <br /> EPA/Other <br /> J. Additional D Mona,for Materials listed Above K. Hanelling Codas for Wo"Wed Above <br /> �ItI C( a, ,( b. <br /> c. d. <br /> 15, Special Handling Instructions and Additional Information <br /> � <br /> .(►'jC s!r,�r(, M :r. ' 1L �r�t; ) <br /> 16. GENERA R'S CERT IFIC ON: I hereby declare that the contents of this consignment are fully and accuratelydescribed above by proper shippfrig name and are clossified,packed, <br /> marked,and lob-lad,and are In all respects in proper condition for transport by highway according la app'icable international and national gavernma^t regulations. <br /> t If I am a large gvaMity generator,I cenify,that 1 have o pr ram in place to reduce the volume and toxicity of waste generated to the degree I have daterminad to be economically <br /> practicable and that lave selected the practicable method of treatment,storage,or dieposol currently available to me which minimizes the present and future ihreW sa human health <br /> and the environment;OR,if I am o small quantity gnnerolor,I hove 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 /> Primed/Typed Nome Signature Month Day Year <br /> T 17. Transporter 1 Acknowl ant of Receipt of Materials <br /> A Printed/Typacl N ee ,,` Signature r: Month Day Year <br /> s C..t = 1 <br /> P <br /> 18, Trans rter Acknowled errant of Recei t of Moterials <br /> R Printed/Typed Name Signature Month Doy Yaar <br /> T <br /> E <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest axc92f os noted in Item 19, Month Day Year <br /> T Printed/Typed Name Signature <br /> r <br /> DO NOT WRITE BELOW THIS LINE. <br /> SC 8022A(1/99) Ai'— GENIfRATOR RETAINS <br /> A 8700-22 <br />