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state of Cohfornro—Ennronmentol Protection Agency �� � <br /> Form Approved OMB No 2050-0039(Expues 9 30 99] See Instructions on back of page b Deportment of OXinto Substornoo Control <br /> Please print or type Form designed for use on chit 112 pitch)Type—der Sacramento California <br /> 1 Generotor s US EPA ID No Manifest Document No 2 Page 1 Inlormot,on In she shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal low <br /> WASTE MANIFEST 'I t =' '� - ' L, { ' of �, <br /> 3 Generotor s Name and Mailing Address A SsaVe Manrfesl Document Numbe=r. 2- 1 y <br /> -cc <br /> 6 6A 18 <br /> 1140F t S IF T DI-IF- I.l r rpt dT 3 0C Y,. Ir f� 3-15"D B Stale Ganorator s JD nye ` <br /> uj A Generator 7 phone ( r �1' �1—,4 <br /> 5 Trans over 1 Com ort Nome 6 US EPA ID Number C Stoic 7ransport^e�s 1D, <br /> f� ` <br /> b I 'DF _C r_ 01L- +_ t-t J _ v_ fl 7ransportor 7 sana b_ f 20 .. <br /> B US EPA ID Number E Stole`3ransportel7 1DF .�Rt �,S`.;sVtr��,- _ti.L.++ J <br /> 7 Transporter 2 Company Nome f nr j <br /> a <br /> ,7ransporter s Phone _ 5'' �. <br /> G State focrb s ID <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number ,a �f�j , � <br /> H facility Phone <br /> — 7� <br /> F (l <br />(Ij <br /> 12 Consornefs 13 Total ld Unit <br /> 11 US DOT Description(including Proper Shtppmg Name Hazard Class and ID Number) No Type Ovarrt,ty Wt/Vol J Waste Number State2,r :1, ' <br /> t i -F _ r �= 1-t I. f t` !'"I I t i I i .- 1 ; i s 7 �, _ :,r _ <br /> -I- a Q r ' EPA/Oilier <br /> E b State r <br /> p E EPA/Other <br /> c Rc1q <br /> ,, r <br /> A c State <br /> q Q EPA/Oiber <br /> R Y <br /> Lu d . <br /> Z EPA/Other + t <br /> u <br /> V <br /> 3 Adddianal Descriptions for Materials Luted Above y K Handling Codes for Wastes Listed Above A <br /> b <br /> TANK- POT TOI'i t4ASTE ` <br /> Lu t f�r-1-'f= c d <br /> Q � - •y � e �-z <br /> 0 15 Spec,ol Ha ndllag InstruOrons and Addit-o nol Dor mote on <br /> < ,F "F-0rE--+=Tlt'E= ,-;_r1fHIr;1a - <br /> z Flas_I F-1% - € 1_(ai ,"l=3 y Via ; "'': j - - <br /> 16 GENERATOR S CERTIFICATION I hereby declare the,toe contents of this consignment ore fully and accurately described a6ove by proper shipping name and are clossi(ted pocked <br /> d marked and labeled and ore In all respects in proper condition for tronsport 6y highway according to applicable nlernet onol and not onol government regulations <br /> J <br /> _ If I am a large quantity generator I certify thin 1 hove o program m plate to reduce the volume end to iuy of waste aeneraled to the degree l have determined to be economically <br /> 4 promccible and that I hove selected the prochcoble method of treatment storage or disposal currenky ovmla6le to me which minimizes the present and future threat to human heal=h <br /> and the ennronment OR If I am a small quantity generator I hove made o good fodh effort 10 mmimi.e my waste genet <br /> and seSecl If,e best waste management methot i at u <br /> ce ova=la6le to me and that I con cffo,d <br /> Signature Mont Day Year— <br /> >. <br /> ear <br /> >- Panted/Typed Nome 1 <br /> 1 17 Transporter 1 Acknowled emen'of Rece= 1 of Motenol5 <br /> R f <br /> Month Day ear <br /> Signature f �e <br /> � 6 Printed/Typed Name _ U <br /> L $ ttil r i ( : 1 <br /> T <br /> Il! P 1 1- 11 <br /> i 0 16 Trons orter 2 Acknowledaemenl of Recei I of Me'encls <br /> Month Day Year <br /> 0 S Printed/Typed Name Signature <br /> u E <br /> � g <br /> d <br /> V 19 Ducreponcy Indlcat�on Space <br /> F <br /> A <br /> C <br /> I <br /> 1 24 Faah C)wner or O erator Certi(icohon of rice t al hcxordous materials covered b this manifest exce t as Holed in Item 19 <br /> j Frinled/Typed Neme Signe vre t Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br /> C,clnEK-,0R RETAINS <br /> EFA $700-22 <br /> �Y w <br /> l <br />