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tato of Caldomia--Environmental Notectwn Agency <br />� Appro*d OMB NO 2050-0039(Expires 9 3496) See InitrWCh*ns all back of page 6 Department of Toxic Substances Control <br /> - TIM vrty designed for use on elite(12yrrch)typewriter Socromento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA 10 No Manifest 0ocument No 2 Page 1 Information in the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST `` r c T ( r r'' I ' I of <br /> 3 Genglator sLN�e and Moilmg Address , a f y �✓ n r A. <br /> I <br /> 4 Generator s Pnone <br /> M > <br /> U� <br /> 5 Transporter 1 Company Name 6 US EPA ID Number G`gSLCIt!T <br /> 'Y—t 1 t I I E.'atiF s i J' <br /> �• 3�l..r i j r D +� <br /> 7 Transporter 2 Company Name 8 US EPA ID Number <br /> s- <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Numbertt <br /> �4 <br /> 12 Containers 13 Total ld Unrt v x` r+��?t.ef, <br /> 11 US AOT Description(including Proper Shipping Name Hazard Class and OD Number) No Type Quantity Wt/Val 1 Wadi z <br /> - <br /> _ lr f1 <br /> G I -i EPA + <br /> N b SMta, t r <br /> E F <br /> r $4. <br /> R EPA <br /> A <br /> T c } <br /> O <br /> R <br /> EPA/ <br /> rI <br /> ERA% <br /> rti f= 3613:5 <br /> .'16JJ.iV :�" s._s,-+ "�' y �,�dr �r h, r 4✓���5' rf�fa.�. <br /> 15 Special Handling Instructions and Addrtional Information <br /> 16 GENERATOR S CERTLACATION l 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 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 qua"generator I certify that I have a program in pkxe to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> econamtcolly practicable and that i have sek-ded the practicable method of treatment storage of disposal currently available to me which minimizes the present and future <br /> threat to human health and the environment OR d l am a small quantity generator t hove made a good faith effort to minimize my waste generation and select the best <br /> waste management method that is available to me and that I can afford <br /> Printed/Typed Name Signature 1 Month Day Year <br /> T 17 Tronspprter T Acknowledgement of Receipt of Materials <br /> NPrintedlyped Name Sigr atvre , Momh I Day Year <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> 11 <br /> T Printed/Typed Name Signature Month Day year <br /> T <br /> E <br /> R <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> 00 Fact Owner or rator Certification of recem t of hazardous mofenals covered by this manifest except as noted in item 19 <br /> T Printed/Typed Nome Signature f { Mouth Day <br /> V <br /> DO NOT WRITE BELOW THIS LINE <br /> t C+ Ij4� _-F C:� i ,- _Cri T3 -lI InH JTZ <br /> �Jr'r1C r^SCi no _t^mit }ozz.r)ous a,tc _ J J <br /> TSC 8022A (1/95) <br /> PA 8700-22 <br />