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State of Colifemia--Environmental Protection Agency <br /> See ilnstru6tioni On back of - ,qe 6. Department of Toxic Substances Contro' <br /> Norm ApLed OMB No.2050-W39(Expires 9J494) <br /> Please print or type. !I Form designed for use on elite(t2-pitch)tyrW. Sacramento,Coliforms <br /> f. Generators US EPA ID No. Manifest Document No. 2. Page.1 Information in the shaded areas <br /> / J is not required-by Federal law. <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST f i <br /> 'O 3. Generator' 'amg a[id Mailing Address <br /> LO <br /> Ln <br /> tV 4. Gener�otor's Phone ( ) C, �� i i { <br /> l ao <br /> O 5. Transporter 1 Company Name 6. S EPA ID Number00 <br /> Tkotstlloiter tG <br /> ?§ <br /> k _j 7. Transporter 2 Company Name 11. US EPA ID Number »= x <br /> Upas <br /> Q <br /> Z 4- Designated Facility Name and Site Address 10�US EPA ID NumberILO y t <br /> 41torie <br /> 14) <br /> 621 11 <br /> N U 12. Containers 13, Total 14. Unit <br /> Z 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> No. Type Quantity wt/Vol 1 WO M hNlmbd <br /> Cr) 3 G �,' tat �. J'� PAfer <br /> C4 <br /> oo N b. Xe <br /> v R _ TPM : <br /> A �/ tLt = l - <br /> T C. <br /> co <br /> 5#ate <br /> tr <br /> R IPA,fWC>rhtr <br /> LU <br /> Z d. <br /> LU �� f!A�dHtar 3 <br /> Z r*Vriile3 lssfed'Afwve <br /> a z b <br /> Uj <br /> Z <br /> Q 15. Special Handling Instructions and Additional Information <br /> Z <br /> LU <br /> 1 16. GENERATOR'S CERTIFICATION; I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified, <br /> i Q Packed,marked,and labeled,and ore in all respects in proper condition for-transport by highway according to applicable federal,state and international lows. <br /> U -- <br /> If I m a large quardiiy 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 treatment,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 generator�l_}tpve made a good faith effort to minimize my waste generation and select the best <br /> wa mane ement method that is araila6le me and that I can afford, i ) <br /> O Pri e; r Signature.' r Month Day wear <br /> Gig=�/�/1�' <br /> Z T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> w R <br /> A Printed/Ty/ed Name_ � � Signal/ares/�-/ � �Month Day YearC� <br /> W 5 �// �.f `.i C✓ I I <br /> P <br /> 0 18. Trans orter 2 Acknowledgement of Receipt of Materials <br /> w Signature <br /> T Printed/Typed Name - Month - Day Year <br /> LL <br /> O a <br /> L19.n1Discrepancy Indication Space <br /> U A <br /> 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by thkF' anifest except as noted in item 19. <br /> T Printe LTyped Name r Signatu{d, Mon1h fear , <br /> DO NOT WRITE .BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 50 DAYS, <br /> DTSC 8022A (7/92), (Generators who submit hazardous waste for transport oui-of-slate. <br /> EPA 8700-22 0 produce compfeted copy of this cegy and send Io-OTSC ;Pirhin 20 days.) <br /> l 4 - <br />