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J <br />Q <br />N <br />State of Cuiifornia—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30-99) See Instructions on back )age 6. Department of Toxic Substances Control <br />-Please print or type. Form designed for use on elite (12-pitc.., .ypewriter. Sacramento, California <br />O <br />tr7 <br />h <br />N <br />C <br />00 <br />O <br />C <br />CP <br />Q <br />U <br />Ce <br />LL <br />Z <br />LL <br />U <br />LL <br />u^, <br />Z <br />C <br />LL <br />a <br />G <br />2 <br />C <br />a <br />Z <br />LL <br />2 <br />C <br />1. <br />Z <br />DO NOT WRIIE BELOW TWIS LINE. <br />Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (4/97) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />UNIFORM HAZARDOUS <br />1. Generator's US EPA ID No. Manifest Document No <br />2. Page I <br />Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST <br />of <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number985221471 <br />{y,52e+ <br />- <br />B. State Generator's ID <br />4. Generator's Phone ( J <br />5. Transporter I Company Name 6, US EPA ID Number <br />C. State Transporter's ID <br />D. Transporter's Phone <br />7. Transporter 2 Company Name .. 8.., US EPA ID Number <br />E. State Transporter's ID <br />F. Transporter's Phone <br />9, Designated Facility Name and Site Address 10. US EPA ID Number <br />- <br />G. State Facility's ID <br />cy sys�z�� <br />- - <br />H. Facility's Phq= <br />••, <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) <br />12. <br />nt <br />Coainers 1 <br />113. Total <br />Quantity <br />14. UnitNo. <br />Wt/Vol <br />I. Waste Number <br />Type <br />. , r. - - r_ , 1 . r` <br />��Ul.� > !�J%1� F. L... 5'_., , 0 <br />State• <br />2 <br />G <br />�S <br />f 1'JM I F t, �i I_ l_.iL)'---iC .1 <br />EPA/Other <br />E <br />N <br />6. ( <br />State <br />E <br />EPA/Other <br />R�`> <br />A <br />.. <br />T <br />c N ��c�`w <br />State <br />O <br />EPA/Other <br />R <br />d. <br />State <br />EPA/ Other <br />J. Additional Descriptions for Materials Listed Above <br />K. Handling Codes for Wastes <br />Listed Above <br />iV\1K _BCIT-rOrl W�aS*I- . <br />a 61 <br />b' <br />c. <br />d. <br />15. Special Handling Instructions and Additional Information <br />r��'�'�:c,PP.I A-rr- r'E?r•-1..; f: _...,...r,; f_. I.:_.r;"FH T NC -i <br />S'- T ).- c <br />'I CI"lr.r'L r,..11_'v t_ 1t.a , �.... ,. , ? <br />1 F; .i, s: . <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 quantify 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 am a small quantity generator, I have made a good faith effort to minimize my <br />waste generation and select the best waste management method that is <br />available to me and that I can afford. <br />Printed/Typed Namett�� <br />• v i �9 <br />Signature/ <br />Montlj, _ ,ay,. -`—,7y ay, .. -- f.Y <br />w , �',� <br />LartrJ. <br />R17. <br />Tran(porter 1 Acknowledgement of Receipt of Materials ,. <br />4 <br />Printed/Typed Name <br />Signature <br />�doryiNF1_r- �i/ G 1V[ <br />018. <br />Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this a t st except as noted in Item 19. <br />T <br />Printe Na%�a ` <br />Signature / <br />' / <br />t Day Year <br />C <br />DO NOT WRIIE BELOW TWIS LINE. <br />Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />DTSC 8022A (4/97) (Generators who submit hazardous waste for transport out-of-state, <br />EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) <br />