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Slate of Caltformo—Environmental Protectton Agency <br /> Form Approved OMB No 2050-0039(Expires 9 30 991 See Instructions on bock of page 6 Department of Toxic SVb5lan[e3 ton <br /> Please print or type Form designed for via on etre 112 prtch)typewnler Socromento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page I Information in the shaded areas <br /> .s not required by Federal law <br /> WASTE MANIFEST { I �' - t = of <br /> 3 Generator s Name and Mailing Address A State Manifest Document Number Q/y��/yt� R <br /> 1 r1 t IJ1I�� r-t�IJi htl c i;1 [-I` V.0 ,112,11 J 81 <br /> NF,c;- L-IF ? „_F Iw T, AN I i.1 t-I I-A ?.f y 8 State Genarator's ID <br /> U-1 4 Generator s Phone <br /> N 5 Transporter] Company Noma 6 Us EPA ID Number C State Transporters ID� _ ✓ ^ t .. <br /> m i I_i -t I _l I t_ I_ t i _ L - r <br /> O Transportar's Phone <br /> co 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID <br /> F Transporters Phone _ <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Fadfsty s 10�-� f -I <br /> Q ,t11=r 1 - I tI IeJr jV/ /(L <br /> Z r ^. _ r,( (`3 i_t r - H Facsily Ph G <br /> 0 -_1I r` t< . �1 =� 1 {i r�w1 ., sI _ l[ � <br /> 12 Contomers 13 Total 14 UI <br /> Q 11 US DOT Description(including per Shipping t (includProShing Name Hazard Class and 1D Numbed <br /> ;1V No Type Quantiy wt/Vol I Waste Number <br /> Slotoi <br /> t'a 1 _ 1 (: ISI �- i =Y (-�i Ic I i^i; "r 7i 11 _�.•.i <br /> ' ; EPA/Other <br /> O N b state <br /> co <br /> E EPA/Other <br /> N R <br /> Q A <br /> T State <br /> W Q <br /> EPA/Other <br /> R <br /> iLw d State <br /> F- <br /> z <br /> V EPA/Other <br /> Is.i <br /> J Additional Descriptions for Materials Ustod Above K Handling Codes For Wastes listed Above <br /> TANK POTTOM WASTE a � ' b <br /> Lw <br /> F'Fh�5Fx s S - Y a i� d <br /> z <br /> O 15 Spenaf Handling Instructions and Additional informal,on <br /> QF1- r;, TLi �C ," t_T, <br /> yrifLu <br /> -C {= <br /> r � <br /> 16 GENERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and ore classified packed <br /> Q marked and labeled and ore in all respects m proper condition for transport by highway according to opphcable international and national government regulations <br /> V <br /> If I am a large quant,y generator I certify that 1 hove o program m place to reduce the volume and toxicity of wosie generated Io the degree I have determined to be economically <br /> a practicable and shat I hhove selected the practicable method of treatment storage or disposal currently available to me which minimizes Ike present and future rhreot 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 generation and select the best waste management method hot is <br /> available to me and that I can afford <br /> O <br /> ]-, printed/Typed Name Signature .' / Month Day Year <br /> U 1 f r <br /> L <br /> z - — - L >, <br /> Luu.l T 17 Transporter 1 Acknowledgement of Rectiet of Matencls /1 <br /> 8 Month Do ear <br /> Lu A Printed/Typed Nome Signarure� Y Z <br /> t <br /> LL- 0 18 Transporter 2 Acknowled ement of Receiat of Materials r <br /> 0 7 Printed/Typed Nome S,gnature Month Day Year <br /> w E <br /> cn ti <br /> Q <br /> V <br /> 19 Discrepancy Indication Space <br /> z F <br /> A <br /> C <br /> I <br /> F 20 Foc;lt Owner or Operator Certification of receipt of hazardous materials covered bX his manifest except as noted in Item 19 <br />\�J <br /> Printed/Typed Nome Signature Month Day Year <br /> Y <br /> DO HOT WRITE BELOW THIS LINE. <br /> DTSC 8022A 14/971 c <br /> EPA 8700-22 <br />