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Store of Californio—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Deportment of Toxic Substances Control <br /> Neosd print or type Form designed for use on efde 112 pitch)typewriter Sacramento California <br /> UNIFORM HAZARDOUS 1 Generators US EPA ID No Manifest Document No 2 Page 1 Information in she shaded areas <br /> WASTE MANIFEST , s not required by Federaf low <br /> + 5" 5 of <br /> 3 Generator s Name an��d��Marin Address A State Manifest Dowinneni Number a '" (/�55 <br /> CHASE <br /> P <br /> t� E �fl.1.,:iC g `fit r ���� c 9 ��#` 55 <br /> LTi ) t ` !-.T�'`i..+i 4 ^h^. T <4 'Iii' J_.r„ _,* <br /> 0 423 N. ADMON. STOCKTON, CA 9J`�.2G�, TS' State ID <br /> sr' >� <br /> A Generators Phone { { <br /> r y ' i i _ <br /> N 5 Transporter 1 Company Nome 6 US EPA IA Number C State Transporters 7D{Reserved) <br /> 00 h r <br /> p D Transparter,'s�sanes'd ""x�'m�e`ra=" �' ,. <br /> 7 Transporter 2 Company Nome 6 US EPA ID Number E State Transporter's ID[Reserved I,, <br /> Q F TransportiiPhone <br /> U 9 Designated Facility Nome and Site Address 10 US EPA ID Number G State facility's ID,' <br /> a P MERICLSEA1d, DiC.. Y <br /> LOM Z'5i0 AL,PIOND L)R. H Facility's Phone <br /> C, 4 e 117 Gi 7 fi '7 �f t <br /> A r, <br /> Q a� �` 'y Y;n«. + ; <br /> U 11 US DOT Description Iintludmg Proper Shipping Nome Hazard Clpss and ZNumber{ 12 Containers 13 Total 14 Unit 7,No Type Quantity WI/Val 4 Wa is a Number,` <br /> aState <br /> z <br /> �z sta <br /> HOU-PC PA HAZ AF.ItI:)l�� 14,' 31 � I. 1011-[1[3 ite,{ <br /> ~ EPA/Otheer.(Ill K WATER) <br /> C a+ r <br /> Nb State = r ', 1, <br /> co E <br /> iu <br /> c R EPA/Other, <br /> v A h <br /> a <br /> State 'y s r <br /> T <br /> 0CC) O t' M eq <br /> R EPA/Ocher- �- <br /> LU d ]�E <br /> tate; <br /> Z <br /> W PA/Ocher <br /> Uu <br /> ) Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> PURdE: WATERa b � a, <br /> L <br /> { d 7 <br /> � 4 <br /> Q <br /> Z 15 Special Handing Instruct>ons and Additional Inlormalion <br /> O <br /> a f.f FI"ttjPP,A,,2 Pert rF f it r_I 111 11111(1 <br /> 'Z Ir-I1Ef%+FRC1f t 1314T'AC 12 I,--I 3 t d343 '!I4•_0r <br /> _ <br /> SEF E.F? ln. IV <br /> 16 GENERATOR S CERTIFICATION I hereby declare that the contents of thss cors. nmeni are fully and occurotely described above by proper shipping name and ore classified pocked <br /> 'a marked and labeled and ore in all respects in proper condition for transport by highway according to apphcoble mternorional and notionol government regulations <br /> If 1 am a large quantify generator I certify that I have o program in place to reduce the volume and toxicity of waste generated to the degree I have determined o be economically <br /> n. practicable and Ihoi I have selected the practicable method of treatment storage or disposci cvrrently avoidable to me which minimizes the preserl and future threat to human health <br /> Ln <br /> and the environment OR it I am o 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 /> x ovailpble to me and that I can afford I <br /> O t r <br /> r Printed/T ped Name i Signature } r �/"� Month, Day Year <br /> f f ( r <br /> T 17 Trans, Iter 1 Acknowieclemenl of Recei t of M densis i 1 <br /> R "1 <br /> LU A Panted/Typed Norr1e r J , Signature ) Month Day Year <br /> a 18 Trans order 2 Acknowled <br /> R Prirted/Typed Name signature Month Day Year <br /> LU E <br /> � R <br /> V19 Discrepancy indication Space <br /> z F <br /> A <br /> �^ I <br /> E20 Foci Owner or O erotor Certification of recei t of hoz.rAcu,materials covered b this manifest ecce t os noted in Item 19 <br /> Printed/Typed Nome Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> ' DTSC 8022A {1/99) <br /> EPA 877D0---0-22 Yellow GENERATOR RETAINS <br />