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lifornia.-- <br /> EnvirtinmeMol Protecliort Agency � <br /> ved OMR No.2050-0039(Expires 9-30-94y = See Instructions on back" a 6, <br /> Pr type, Form designed lot use on elite 12 itch g Department of Toxic Substances Conhr <br /> iM or ,g ( p J typewriter, <br /> Sacramento,California <br /> UNIFORM HAZARDOUS 1- Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas <br /> WASTE MANIFEST j ! is not required by Federal law. <br /> Q / OF of I <br /> 3. Gene�r(a'for"s Name and Moiling Address <br /> W) �r, .+:� 4'T"�r,%�nr[Grp/F,oa7 �c ,�� ��v�r.,v.v A 8roro hia Desi tTbctrnxpf.flu M <br /> E� <br /> n /as'.jr!ooh �s [S7�r E T St�xk ova; C u!,i�ar,'� t�S Nye <br /> C14 <br /> 4. Generator's Phone (��) [� C/( G pQfitii4 GQf(erafa FY k <br /> O V 8 <br /> mS_ Transporter 1-Compony Name b. US EPA ID Number g <br /> Q43S56 <br /> 7- Transporter 2 Company Nome S. US EPA ID Number <br /> ^ <br /> f <br /> �y Q 9. Designated Facility Name and Site Address 10. US EPA ID,Number <br /> 00 a R*M EN IRON UAL SFRVICES <br /> OO U_ 1515 SOUTf3 RIVvR ROAD WSST SACWIRM ;µCA 95591 <br /> r..� <br /> aIC 10 14 0 Q 13 1515 16 <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Numb <br /> 12- Containers <br /> Number) 13. Total 14. Unit <br /> No. T Quantity Wt/vol <br /> an/i]K !'T G +�f�' fy-'a�,�'G�oK 3 Lt�a ofC �.�/ •C-! �' i <br /> . ,.�'' - �- '$ir'r�..rr- �� �•�.� _ �a�ar ✓ter <br /> 01019 n ifit 1.0,10y 16lb� , <br /> 00 'E // is <br /> 4N � a2G✓c�pu$ u<c� �„ � . <br /> mT C. y •m <br /> R _ & pig�J ? , <br /> w <br /> - <br /> Z <br /> w <br /> U <br /> LU <br /> Z }„i 3Addrttonal .-r, '�gr,Alate fa It= Hat,dlltr ,Lode3:, t j&, -.- <br /> Uj <br /> ON <br /> 0. <br /> r. <br /> Z 15 Special Handling Instructions and Additional Information <br /> a WIND ERS ' 40 1"D3f? OSHA/SARA TRkUgED <br /> Z <br /> LU AND USE.NIQPH APPROVED PPE. f 1A � 31 <br /> _ F14RRGRNCY 63NTWr: 916-371-5747. <br /> J 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping'nome and are classified, <br /> Q packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable internationol and notional government regulations. <br /> V <br /> If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> -� economically practicable and that I have selected the practicable method of Iireptment,storage,or disposal currently available to me which minimizes the present and future <br /> threat to human health and the environment;OR,if_I am a small quantity genet have made a good faith effort to minimize my waste generation and select the best <br /> - - ste A.na enrent-method that ova""bte to me-ad-that'i con A <br /> i F <br /> >_ P, Ty ed Name Sign MonthD <br /> e, U <br /> V 17, Transporter 1 Acknowledgement of Receipt of Materials <br /> Z t <br /> Printed`/Ty d Nome 11 <br /> LU w Si ` e - Month Day Year <br /> � 5 V/1 - O <br /> LLJV <br /> 0 18. Trans Drier 2 AcknowlEdgement of Receipt of Materials <br /> u.l f Printed/Typed Nome Signature Month Day Year <br /> sL E <br /> O p <br /> LU 19. Discrepancy tndication Space <br /> Q F e <br /> V C <br /> Z 1 <br /> L <br /> 1 20. Facil"y Owner or Operator Certification of recei6t of hazardous materials cover this manifest except as noted in Ittrn 19. <br /> "T Print Typed Name Signator Month Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> `. Yellow: TSDF SENDS THIS COPY TO"GENppATOR WITHIN 30 DAYS. <br /> DTSC 8022A (9/93) (Generators who submit hazardous;waste for transport out-of-state, <br /> EPA 8700-22 .: produce completed copy of this cWy and send to DISC within 30 days.) <br />