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State of Caltfornia—Environmental Protection Agency <br /> Form Aan"Cd OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 <br /> ' p p Department of entc Substances Control <br /> Please prr6Y ar type Form designed kr use on,eGre 112 pitch)typewriter Sacramento Cpl,Forma <br /> 1 Generators US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS <br /> -q u netrequired by Federal low <br /> WASTE MANIFE5T 1a 1 y 3 � 3 of 3 <br /> ' 3 Genera r s pfibm8 and Mailing Address A State Manifest Document Number p <br /> CIfX51--UADr,0 20.835234 <br /> 423 4 MADISON, `S M,"K i ON,CA 95202 8 State Generator s ID <br /> ' ^ d Generator s Phone ( 209 y 46 i-1005 V 'H { <br /> LO <br /> 5 Transporter 1 Company Name 6, US EPA ID Number C Store Transporter s 0Reserved f <br /> «./ <br /> [7 �"s .+. µ D Transporter s Phone <br /> 010 <br /> e!#L. �.f fl.. 4r t 4 i I <br /> 7 Trdnsporter 2 Company Name 8 US EPA ID Number E State Transporter s ID Reserved] <br /> F Transporter s Phone <br /> U t e�gn� tle Address 10 US EPA ID Number G State Facility's ID <br /> z <br /> 243TLI AILMOND 9V <br /> H Faci ity's Phone <br /> U11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) 12 Containers 13 Total lit Unit <br /> No Type Quantity Wt/Vol I Waste Number <br /> ` )N RCRA HAZARDOUS Wks rF- I~ionic State i <br /> 3 (OIL � WA TER) 22 <br /> ' l EPA/Ocher <br /> C14 <br /> N b State <br /> m E " <br /> .y R EPA/Other <br /> ' v A <br /> Stale <br /> opo O <br /> R r EPA/Other 1 <br /> f <br /> ' w d State <br /> Z <br /> LU <br /> U EPA/Other <br /> LU <br /> ' J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> IL&WATERLLA <br /> ' <br /> d <br /> c <br /> Z <br /> a <br /> Z 15 Special Handling Instructions and Additional Information <br /> 16 GENERATORS CERTIFICATION I hereby declare that the contents of this constgnment are fully and accurately described above by proper shipping name and ore classified packed <br /> Umarked and labeled and are in all respects in proper condition for transport 6y highway according to applicable international and national government regulatians <br /> ' J <br /> �_ if I am a large quantity generator I certify that I have a program m place to reduce the volume and taxictty of waste generated to the degree I have determined to be economically <br /> d practicable and ihat I have selected Ike 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 waste generahon and select the best waste management method that is <br /> a� available to me and[hat I can afford <br /> O <br /> Pante y e ami Si dnatore� Month Day Your <br /> R17 Trans orter 1 Acknowledgement of Receipt of Materials <br /> W p Printed/Typed Name Signature Month Day Year <br /> IU- p 1$ Transporter 2 AcknowWed ement of Receipt of Materials i <br /> TPrinted/Typed Name Signature Month Day Year <br /> W E i <br /> N R <br /> ' U F 19 Discrepancy Indication Space <br /> Z A I <br /> C l <br /> 1 ` <br /> ' t <br /> 1 20 Facilt Owner or O orator Certification of recei t of hazardous-waYenals covered by this manifest except as Hated in Item 19 <br /> Y PrmtedlTyped Name J r Signature J ' J t Month Day Year <br /> 6' i <br /> Ile <br /> 1 / <br /> DO NOT WRITE BELOW THIS LINE <br /> Yellow TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS E <br /> DTSC 8022A (1/99} (Generators who submit hazardous waste for transport out of state <br /> EPA 8700-22 <br /> produce completed copy of this copy and sena to,DTSC within 30 days] <br />