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State of Cvlifornia—Environmental Protection Agency <br />Form Approved OMB No. 2050-0039 (Expires 9-30.99) See Instructions On bad page 6. Department of Toxic Substances Control <br />Please print or type. Form designed For use on elite (12-p. 1pewriter, Sacramento, California • <br />O <br />h <br />to <br />N <br />LO <br />a0 <br />O <br />O <br />00 <br />Q <br />�U <br />Z <br />�Ce <br />�O <br />LC7 V <br />C\.iZ <br />�3 <br />c� <br />0 <br />as <br />ao <br />v <br />N <br />d <br />C <br />C <br />aC <br />LL <br />LL <br />F <br />Z <br />LL <br />1, <br />V. - <br />C <br />LL <br />Ck <br />Z <br />C <br />a <br />LL <br />F <br />l <br />U <br />a <br />C <br />s <br />U <br />C <br />L <br />L <br />c <br />DTSC 8022A (4/97) <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Yello,, TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />produce completed copy of this copy and send G DTSC within 30 days.) <br />V <br />UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2 Page I Information in the shaded areas <br />is not required by Federal law. <br />WASTE MANIFEST{ of <br />f c. _ t <br />3. Generator's Name and Mailing Address A. State Manifest Document Number (Q�"�2519 .7®,©� pQ <br />l-•� f�r ll J 1 <br />J/1 .i �_)�:(���� ?'�(.'>'l '' `'1 `J -• '. B. State Generator's ID <br />4, Generator's Phone oA 1 ;•"1 ; <br />5. Transporter 1 Company Name 6 US EPA ID Number <br />C. State Transporter's ID <br />k <br />D. Transporter's Phone U <br />r I <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 />G. State Facility's ID <br />F <br />al 51d Ua l- ;-n� <br />H. Facility's Phone <br />2 fU t^�G 1 ^µ , <br />�C <br />-35 7%3 <br />11. US DOT Description/(including Proper Shipping Hazard Class, and ID Number) <br />12. Containers <br />13. Total <br />Quantity <br />14. Unit <br />Wt/Vol <br />I. Waste Number <br />No. <br />Tye <br />/Name, <br />State <br />EPA/Other <br />r <br />/) <br />IT <br />E <br />N <br />b <br />- <br />state <br />E <br />EPA/Other <br />R <br />C. <br />State <br />T <br />O <br />EPA/Other <br />R <br />d <br />State <br />EPA/Other <br />J. Additional Descrriiptions for Materials Above <br />K. Handling Codes for Wastes <br />Listed Above <br />/Listed <br />C/ <br />b. <br />C. <br />d. <br />15. Special Handling Instructions and Additional Information <br />4 ti(eKiu-•v� <br />L( r <br />16. GENERATOR'S RTIFICATIO : 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, 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 avoifable to me which minimizes the present and future threat to human health <br />f <br />and the environment; OR, if I am a smaquantity 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 Name <br />Signature I I <br />Month Day Year <br />.V <br />t T <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />j A <br />Printed/Typed Name <br />Signature / <br />j <br />Month Day Year <br />i S <br />, e, <br />P <br />0 <br />18. Transporter 2 Acknowled errant of Racei t of M16terials <br />T <br />Printed/Typed Name <br />Signature <br />Month Day Year <br />J E <br />> N <br />j19. <br />Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />,L <br />j <br />20. Foci Owner or Operator Certification of receipt of hazardous materials covered by this mqnifest except as noted in Item 19. <br />T <br />Printed/Typed Na <br />Signature <br />Month Day Year <br />Y <br />DTSC 8022A (4/97) <br />EPA 8700-22 <br />DO NOT WRITE BELOW THIS LINE. <br />Yello,, TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. <br />(Generators who submit hazardous waste for transport out-of-state, <br />produce completed copy of this copy and send G DTSC within 30 days.) <br />V <br />