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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back o. i 6. Department of Toxic Substances Control <br /> Please print or type. Form designed for use on elite(12-pitch)tyr ter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS t� is not required by Federal law. <br /> WASTE MANIFEST �' i f� � � '`; � � `� �,; � � 3 of 1 <br /> 3. Generator's Name and Mailing Address A. State Manifest Document Number <br /> U11TRA MAR 21 104590 <br /> 681 W. Third fit. B. State Generator's ID <br /> h 4. Generator's Phone IT <br /> 59 ) JR'3-3751 <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.) <br /> aD D. Transporter's Phone 900 �' 0 ^ <br /> o p 7 1t*Y .CC j1S_�.1 nC� <br /> service-3, rit�`;� ) 'q 3 > 1 P (� J) s.i-..l �r. <br /> 0 <br /> ao 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.) <br /> J - F. Transporter's Phone <br /> J <br /> Q <br /> V 9; esignated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID <br /> d F'?�te. Ree:CLinq Service-, <br /> 1K '4. Monte Ave, H. Facility's Phone r 1 t 7 T ti E) '? <br /> �ialro, CA .92'31`6 A L �1 R ? i 4 4 r} t y J t 1.._- <br /> 0 <br /> 12. Containers 13. Total 14. Unit <br /> Q 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> V No. Type Quantity Wt/Vol I. Waste Num er <br /> Z 6NON R�_7A EAZa:'.REOUS WASTE L.-i CA kA_ 1 +� State r <br /> r� Lj r EPA/Other <br /> E State L <br /> o N b a t�.! r�_C-z2 IN E--A 4N, Z , f_J Cz Q s 7 y` <br /> oo EEPA/Other <br /> v R �.J A S T-1G04 <br /> A c State <br /> o T <br /> co O EPA/Other <br /> R <br /> State <br /> w d <br /> Z EPA/Other <br /> Lu <br /> LU <br /> h J. Additional Descriptions for Materials Listed Above K. Handling Codes for Wastes Listed Above <br /> ;��} b. <br /> Lo <br /> J <br /> Q $ peciAl-clan Iln�.fiis u tY3 a iidy11d"dltional information =/U a,,0C:ji'T',i CPN: <br /> Q _`� L'-f <br /> Z 24 fY}7 Fi•�'., GETJC:Y f 909-i 1-7038 <br /> Lu <br /> 2 <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,packed, <br /> 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 quantity generator,1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined to be economically <br /> o 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 /> N and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> O available to me and that I can afford. <br /> Month Day Year <br /> Signature I i <br /> r Printed/typed Name n 9 _ Lam} / /7 /_ r 1 <br /> Lu T Aly. Tr11 an•S porter l/ cknowled ement of Receiet of M61erials F .1 - <br /> R j ,- i Month Day_ Year <br /> d'Lu N Printed'/Typed Name Sign - / �• ,J <br /> Lu s <br /> u.. 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 R Printed/Typed Name Signature Month Day Year <br /> T <br /> w E <br /> R <br /> U19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <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. Month Day Year <br /> T Printed/Typed Name Signature <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Blue: GENERATOR'SENDS THIS COPY TO DTSC WITHIN 30 DAYS. <br /> DTSC 8022A(1/99) To: P.O. Box 400, Sacramento, CA 9581 2-0400 <br /> EPA 8700-22 <br />