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liFornio—Enwronmantal Protection Agency <br />' F� Nproved OM8 No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite f 12 pitchf typewriter Sacramento California <br /> UNIFORM HAZARDOUS I Generators US EPA ID No Manifest Document No 2 Page I Information in the shaded areas <br /> is net required by Federal low <br /> WASTE MANIFEST 6 1 S` of <br />' 3 Generator s Name and Mailing Address 11,Jk4 ro <br /> A State Manifest Document Number 21576858 <br /> Cexs /tr/4 rE_.3: 7 B State Generators ID <br />' N d Generator$ Phoneocq 637-0771 <br /> ICV 5 Transporter I Company Name 6 US EPA ID Number C State Transporter's ID[Reserved} ., <br /> W _ <br /> C) M <br /> a �t1� i�F ! .e A Transporter Phone <br /> to <br /> �-- 7 Transporter 2 Company Name 8 US EPA ID Number E Slate Transporter s VIRIserved[ '` � 4t -t�Y <br /> 7 Q F Transporters Phone <br /> Q90ignot.Fl Facie fi(q aD�nAd ess 10 US EPA ID Number G State s ID <br /> ZClues clr I <br /> � H Feu s Phone � <br /> ° <br /> rt,,�'ha.A true 4 k 7 l d' X4 3 is/ffl _Y - <br /> VJ 12 Containers 13 otal ld Unit <br /> 11 US D``O``T Description{including Proper Shipping Name,Hazard Cass and ID Number} No Type Quantity Wt/vol I Waste Number <br /> Z a /VVu IIT ,.w +ll�c.i State <br /> ~ EPA/Other► ' <br /> 3 G ►+ r fist x U { <br /> E <br /> N b State <br /> 00 <br /> to E EPA/Other <br /> V R <br /> c State p"4 <br /> o T <br /> Ct <br /> 00 O ` - <br /> R FPA/Other sr rw <br /> a[ <br />' W d State <br /> Z <br /> W ai_'q 1 <br /> V EPA/Other <br /> W r y s <br /> 1 1 Additional Descriptions For Materials Listed Above i K H nd mg Codas for Wastes Listed Above W �, <br /> f J b L <br /> LU <br /> 0 15Special Handling � nspn�diliona! formatwnr, tJ� �! 4 + <br /> N540 <br /> ;L <br /> W <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of thisconsignment are Fully and accurately described above by proper ship ing name and-are classified packed <br /> Q marked and labeled and are in all respects in proper condition far transport by highway according to applicable international and nut ione Pgovernmeni regulations <br /> V <br /> J <br /> � If I am o large quontiy generator I certify that i have a program m place to reduce the volume and toxicity of waste generated to the degree I have determined to 6e economically <br /> a practicable and that 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 I am a small quantity generator,I have made agood-fcMh effort to minimize my waste ge nand select the best waste management method that is <br /> Cie available to me and that I can afford ! <br /> 0 1 4 r <br /> I >_ Printed/Typed Na a Signature <br /> Z fro& r71.1��1 <br /> W T 17 Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> P /Typed Name S,gnatur� � } l �' Month Day Year <br /> LL_ 0 18 Trans orter 2 Acknowled ement of Recei t of Materials <br /> 0 R printed/Typed oma Signature Month Day Year <br /> T <br /> W E <br /> N R <br /> V' V <br /> 19 Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> 20 Foci 11 ar or O erator Cerhftcetfon of re of hazardous materials covered b this man feel except as noted n I m 19 <br /> Printed/T ame / Signature Month Day Year <br /> IDO NOT WRITE BELOW THIS LINE <br /> velEow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS <br /> DTSC 11022A 11/991 (Generators wno submit hazardous waste for transport out of state <br /> EPA 8700-22 produce completed copy of this copy and sena to DTSC within 30 days 1 <br />