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Stateof CaGfomiarEnvironmental Protection Agency <br /> hForm Apreloved OMB No.2050-W39(Expires 9-3094) See'Instructions on back of -, a 6. ` <br /> Please print or type, 11 Form designed for use on elite(12-pitch)ty Kr. /' g Department of Toxic Substances Contre <br /> Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generaror's US EPA ID No. Manifest Document No. 2. Page 1' Information in the shaded areas <br /> WASTE MANIFEST 14 it)10 ( _ f is not required by Federal law. <br /> 3. Generator s Name and Mailing Address © (� of , <br /> A �Cife-Martitest Document Nu r <br /> ��ryry^'r� �/�.i G,(af'i E✓� �.rti'd ./��p�ii,/{.�- �`n'._Jc,.cr�r`aa�c� Mc�,/;llE[''�FUr�.i/srr.c.i�,y g ? .sem ��� 86 <br /> i <br /> IV3 Al o1 M <br /> nG !! - 11.`State�Gerterator,s fD . . <br /> Ln 4. Generolor's phone (��!)17�i6 <br /> 5�0 u � � . ' <br /> d0 5. Transporter 1 Company Name 6. US EPA ID Number C S`tcRe;Tramperter's <br /> y _ <br /> q <br /> R Nr;' Tr.�5=51r.`1-111, Lit4. 14 10 10 13 15 15 6 °D TrCnsporfer <br /> r 7. Transporter 2 Company Name 8. US EPA ID Number <br /> rrwsD a ,V 11 = 7u <br /> �. F Trarnporter s Pftone <br /> K/ Z 9. Designated Facility Nome and Site Address 10. US EPA ID Number G State Facility's ID <br /> 00 0U- 1515 �r r. <br /> i w::._ 7] i,�� � �,� 9-559 H Facil'ety s Phone- <br /> 10 14.14 10 10 13 1515 16 <br /> 91 6411 <br /> 11. US DOT Description(including Proper Shi m Name,Hazard Class,and ID Number) 72. Cantainers 13.eTotal 14. Unit F ' <br /> Z P C gShipping <br /> No. T e Quantity Wt/Vol I Waste.Number`�%kl <br /> State " <br /> Ci 0 (? U Nt Q Q � EPA� �r ; <br /> t\i E l Gr...' ^ <br /> r �. <br /> o N <br /> 00 E b it/ f�G• I f?'G� <br /> A I / I 0106,6 EPA/Others <br /> O T C. II L State ;� ZsOP E <br /> `: <br /> R EPA/Ofhet Y <br /> LU <br /> Z d• _ State ar <br /> w ; <br /> � � EPA�fOtfttSr' f <br /> en f <br /> O '17 <br /> + e f ryi " f P Cts a ffgritffingCddesfor Wa3tes-ttstedpove .=arjR <br /> J"Additional (cons for A4oteaafs:Listed Above" <br /> i <br /> LU <br /> 0 <br /> Special Handling Instructionnss and Additional Information <br /> moi /t J r�1r�T <br /> _ , �r a <br /> Z •.� r r1 3 <br /> _ 1 / <br /> W L' .�::J ?.�1I� T.Si"T']'l4"?:*?'1 753:x:• f ,L l <br /> CT: 916--371 .5747. <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br /> Qpacked;marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national,government regulations. <br /> v 9 <br /> J If I ami`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 treatment,storage,or disposal currently available to me which minimizes the present and future <br /> d threat to human health and the environment; OR, if I am a small quantity generntt>r have made a good faith effort o iniinize my waste generation and select the best <br /> NW ste management method that is available to me and that I can afford. <br /> P'' d T ed Nagme - Sin ' ,� %' Month Day <br /> 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Z p <br /> ILI A Printed/Ty d Nome w1}r Si nature Month Day Year <br /> rlybet <br /> 0 18- Transporter 2 Acknowledgement of Receipt of Materials <br /> W T Printed/Typed Name Signature Mouth Day Year <br /> tL E <br /> O R <br /> Ly 19. Discrepancy Indication Space <br /> Q F _ <br /> I,J A 71 <br /> Z C IO <br /> L <br /> I 20. Facility Owner or Operator Certification of receipt of hazardous materials covers this manifest except as noted in It m 19. <br /> `T PrinT Typ <br /> e <br /> d Name Signatures MontrhJ Dayy Year <br /> DO NOT WRITE! BELOW THIS LINE. <br /> TSDF.SENDS THIS COPY TO GEKti RATOR WITHIN 30 DAYS. <br /> DTSC 8022A (9/93) f y (Generators who submit hozardocs0waste for transport out-af-s:afe, <br /> EPA 8700-22 l produce completed copy of 'his c^py and :end to DTSC '.�irhin 3C CGys.) <br /> i <br />