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n V C L 2 LLLLL ae LL C LL t!, Q L OA C State of Colifornio—Environmental Protection Agency Form Approved OMB No. 2050-0039 (Expires 9-30-99) Please print or type. Form designed for use on elite (12 -Pilch) h er. See Instructions on back of r 6. Department of Toxic Substances Control DO NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) Sacramento, California UNIFORM HAZARDOUS 1 • Gen rotor's US EPA ID No. Manifest Document No. 2. Page 1 nformation in the shaded areas WASTE MANIFEST I is not required by Federal law. of 3. Generator's Name and Mailing Address e A. State Manifest Document Number B. State Generator's ID rr 1 n A. Generator's Phone ( ) N n S. Transporter 1 Company Name 6. US EPA ID Number C. State Transporters ID Reserved.] D. Transporters Phone J 7. Company Transporter 2 CName P P Y 8. US EPA ID Number E. State Transporters ID [Reserved.] J F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID a t_T H. Facility's Phone 11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) 12. Containers 13. Tocol 14. Unit No. Type Quantity Wt/Vol I. Waste Number r, State G EPA/Other N 6. State E R EPA/Other r A > T O C. �G state R PtS� EPA/Other E�l t`td Ob�� i d. EPA/Other t 1. Additional Descriptions for Materials LilAWIEtve K. Handling Codes for Wastes Usted Above b. 15. Special Handling Instructions and Additional Information 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by propershipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable intemotional and national government regulations. If I am a large quantity generator, I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I hove selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future throwto human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste best generation and select the waste management method that is available to me and that I can afford. Printed/Typed Name Signature Month Day Year R17. Trans orter I Acknowled ement of Receipt of Materials N Printed/Typed Name Signolure Month Day Year 5 P . B 18. Transporter 2 Acknowledgement of Receipt of Materials E Printed/Typed Name Signature Month Day Year - R 19. Discrepancy Indication Space F A C I L ( 20. Facili Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted io Item 19. T Y Printed/Typed Name _.. Signature Month Year Day DO NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)