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G <br />State of California—Environmental Prot .,r6n Agency <br />Form Approved OMB No. 2050 Owl' xpires 9-30-99) <br />Please Frinh.ot type. Form desjyuse o�elite 112-1 voewriter. <br />See Instructions On baCl,, _( Page 6. Department of Toxic Substances Control <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A 14/971 <br />EPA 8700-22 <br />RM H " RDOUS I • Generator's US EPA ID No. Manifest Document No. <br />aacromento, Colitornio <br />2. Page 1 <br />Information in the shaded areas <br />ST ANIFEST <br />is not required by Federal law. <br />' <br />4enerat <br />of i <br />ame and Mailing Address <br />G I <br />A. State Manifest Document Number <br />'f <br />n <br />3133 Ark, J <br />,t <br />984- 819 <br />B. State Generator's ID <br />Z) <br />4. Generator's Phone 1 G <br />V <br />n <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />D <br />D <br />p <br />Lam„• —^ q ` <br />1 <br />D. Transporter's Phone <br />Cgi <br />_ <br />7. Trans orter Company Name <br />P P Y 8. US E A ID Number <br />E. State Transporter's ID <br />1 <br />J <br />F. Transporter's Phone <br />i <br />9. Designated Facility Name and Site Address <br />g Y 10. US EPA ID Number G. State F iii D <br />ty d r ,.�;.i- •- rC�.� •C'...`z i �C K t ra Cm C� 0 O Z b <br />r!�*�'rlcTln•1,., <br />'� 3Clp ccfME v ttc.a C,aAy p ` '? <br />��"T ti H. Facility's Phone <br />ms's {C07-11 00 <br />✓`% fi� 9 rZfy <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number( 12. Containers 13. T cal 14. Unit s. <br />No. Ty a Quantity Wt/Vol I. Wpste Number <br />�.1+` Stater <br />" vs �, r(�UI L -•f <br />I t. <br />t r J EPA/Other <br />E <br />�s \ <br />b 1 1 <br />N <br />E <br />State <br />f R <br />EPA/Other <br />A <br />> T <br />i O <br />C. <br />State <br />R <br />EPA/Other <br />i <br />d. <br />State <br />i <br />r <br />t <br />EPA/Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />I <br />14 <br />C. <br />d. <br />15. Special Handling Instru`�ions and Additional ,,formation <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 <br />notional government regulations. <br />If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />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 />and the environment; OR, if I <br />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 />available to me and that I can afford. <br />Printed/Typed Nome _ Signature _- Month Day Year <br />T <br />It <br />17. Transporter 1 Acknowled ement of Recei t of Materials <br />A <br />Printed/Typed Name �•'"' Signature r • /; Month Day Year <br />S <br />r <br />0 <br />18. Trons orter 2 Acknowledgement of Receipt of Materials <br />T <br />E <br />Printed/Typed Nome <br />Signature <br />Month Day Year <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />I <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19, <br />T <br />Y <br />Printed/Typed Name <br />w+� ^'s <br />Signature _- <br />"t <br />Month Doy Year <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A 14/971 <br />EPA 8700-22 <br />