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rr <br />*of Cabliom"--Fannronmental Prv%ct~Agency <br /> n Appro9(Expires 93496) S@B Instructions on back of page 6 _y F Department of Tonic Substances Control <br /> Ise pnrtt m <br /> Form despned for e on*trio(12-pitch)rypewrrter r j Sacramento Calrfomra <br /> All, 1 Generators US EPA ID No Manifest Document No 2 of <br /> 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law <br /> WASTE MANIFEST ' �l �: of <br /> s< <br /> ��rP1�T 4 w,Lng Address r /LfxSiaM' l ri3tier'� ,k <br /> & qy4 <br /> f'X F C Qt r XI <br /> aN <br /> 4 Generator s done <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C 440 <br /> J / 1 n Wyjn <br /> 7'-Transporter 2 Company Nome 8 US EPA ID Number L �� <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number <br /> _ <br /> 12 Containers 13 Total 14 Und <br /> 1 f US DOT Description(including Proper Shipping Name Hazard Closs and ID Number) No Type Ouant:ty Wt Vo L W <br /> aL' '' <br /> r r , � <br /> E 1.1 F, t t,,+ V 1i 1 <br /> N b ` <br /> R <br /> A <br /> T c <br /> Oso aI6 <br /> EP <br /> r <br /> EPA e F <br /> v xyfz t <br /> ar ,rsr ml�",i f- 1 <br /> s..�r -��► � Y 1f � r�i`� � it E <br /> YI • y 1 tw.si2hh'w�u�.'�Ta`34Gs'yG'F. } <br /> 15 Special Handling Instructions and Additional Information <br /> rl41jfit t } r <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 <br /> packed marked and lobeled and are in all respects in proper condition for transport by highway according to appticobte international and national government regulations <br /> if I am a large quantity generator I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> economically practicable and that I hove selected the practicable method of treatmenl storage or disposal currently available to me which minimizes the present and future <br /> threat to human health and the envrronmanf OR if I am a small quantity generator I have made a good forth effort to minimize my waste generation and select the best <br /> waste maria ement method that is available to me and that t can afford <br /> Printed/Typed Nome r Signaturerj,, Month Day Year <br /> 1 <br /> 17' Transporter 1 Atkiicwiedgitmenl of Recn t of MatcnaIs <br /> R Month Day Year <br /> !t Printed/Typed Name Srgnarure <br /> f <br /> 8 18 Trans rhff-WAcknowled ement of Receipt of Materials <br /> Printed/Typed Name Signature Month Day Year <br /> E - - I <br /> 19 Discrepancy indication Space <br /> F <br /> IMP2 <br /> A <br /> C <br /> 0 Facility Owner or 0aerator Certification of receipt of hazardous materials covered bX this manifest except as noted In Nem 19 <br /> Month Day Year <br /> Y PnrstedJTyped Name Signature <br /> DO NOT WRITE BELOW THIS LINE <br /> Yell,7w TSi7F S_-\C5 —ti IS L�Pv To G�141QATCP <br /> Genercter< xha sucmit nczardout wcs`- ' r r•-n N,� cc <br /> r5C 8022A (1/95) 4 .,thi JO da s; <br /> rA 870 22 prcarre cmplPtPd ccay of Ccpy On, ens- o y <br />