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State of Cal iforni Protection Agency <br />' Farm Approved OMB No 20'50-0039(Expires 9 30 991 - ' - See-Instructions on back of page b Department of Toxic Substances Contra; <br /> Please print or type Forrn designed for use on elite f 12 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS I Generator s US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST �Cpl G Q `i5- Q lit 17 S— "i ( of <br /> 3 Generators Name and Mailing Address OU,pP�,L+ moi! A State Manifest Document Number 20244785 <br /> !s <br /> 3k S Ul CG'I04 s f v 7 <br /> SJ B State Generator s ID <br /> Ln'LO 4 Generators Phoney ) "2 CO 7# <br /> Ln 5 Tronsporler 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> 00 <br /> D Transporter s Phone , <br /> � [�J,,, '"t � 4 G U Zf 7 f p <br />'CP 7 Transporier Company Name B US EPA ID Number E State Transporter s ID[Reserved] <br /> O� F Transporter s Phone <br /> U 9 esignnuled Facility Name and Site Address 10 US EPA ID Number G State Fon(ity s ID <br /> Q ]r—uk Gf IfU y�fe p <br /> H Facility s Phone <br /> U° 5,1 64 gsV60 �s31 y�7- 3 71 <br /> Q 12 Containers 13 Total lit Unit <br /> U 11 US 007 Description(includ'in+gProper/Shipping Name tH�azard Class an <br /> /d ID Number) No Type Quantity Wt/vol I Waste Number <br /> 1 <br /> o ��/� f� t�f�(,trGYLS �CrS+C �l�ill� Stale n� <br /> F7 _ EPA/Oiher <br />'3 G <br /> CN N b State <br /> 00 <br /> ciao E <br /> * R EPA/Ocher <br />'`T A c state <br /> C) <br /> T <br /> m O <br /> R EPA/Other <br />'ww d State <br /> Z <br /> � EPA/Other <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> a b <br /> LU <br /> LU <br /> c d <br /> rR&O 17 <br /> 15 Special Hanr71 lingJ Inf <br /> nstructions and Additional ormation <br /> Use S�G�vsa L( —�r J 7t7 <br /> 11C g-kh'tr ljClPwles �vh 37-l�77I {'1C�4�F'�W / dyy <br /> LU At <br /> r <br /> Q16 GENERATOR 5 CERTIFICATION "I hereby declare that the contents of this consignment ore fully and accurately described o6ove by proper shipping name and are classified packed <br /> U marked and labeled and are in all respects in proper condition for transport y highway according to applicable international and nahonal government regulations <br /> _ f I am a large quarlity generator I certify that I have a program in plaQe to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable on rhot <br /> I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future threat to human health <br /> V) <br /> and the environment OR if!am a small quantity generator I hove mode a good faith effort to mammae my waste generation and select the best waste management method that is <br /> ce available to merand that I can afford <br /> O <br /> 1>_ Printed/ ed Nom6 re i Month Day Year <br /> U r <br /> Z Signatu <br /> � <br /> w T 17 It, orter I Acknowled ment of Rec2 t of Materials <br /> R <br /> APrinted ed Name f�'� Signature �1s />r Month Day Year f <br />�i�c i P <br /> w 0 18 Transporter 2 Ac nowled ement of Receipt of Materials <br /> 0 T Printed/Typed Name Sign otu re Month Day Year <br /> LU E <br /> V) R <br /> F <br /> lU 19 Discrepancy Indication Space ` <br /> Z A— <br /> C <br /> I <br /> L <br /> I 20 Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T Printed/Typeck Npmie ,s SignatRt-11 <br /> � nth Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> Y <br /> DISC 11022A 11/991 L <br /> EPA 8700-22 <br />