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$tate of Coliforntn—Environmental Protection Agency <br /> Form Approved OMB No 2050-0039 lExpires 9 30 991 1 Sae Instructions on back or +fie 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on elite f 12 pilchr`_ writer Sacramento California <br /> UNIFORM HAZARDOUS 1 Generator s US EPA ID No Manifest Document No 2 Page 1 Information in Ike shaded areas <br /> WASTE MANIFEST ! / f r / ,-7 at s not required by Federal law <br /> 3 Generator s Name and Mailing Address /6v r ^ 1 GAS State Manifest Document Numlze <br /> carr, 4 t�f <br /> all <br /> +- <br /> O0Ln ���yyJr ��� 41er4tofrs. �` „ '' 't <br /> A Generators Phone <br /> N 5 Transporter I Company Nome 6 US EPA ID Number iSlate Trunspo�rsfer`s 1D(Reserved I rash 5' <br /> 'n ,+. <br /> 00 4y Ap T , <br /> Q r YYp IAi MlisW V/tr r V� �hl� G Tr` P fr 5 i Z -7 8, 7 IZ IST PC�s� <br /> O L-� f Y rry J s 1_ %J r a. I W • Y &' {TlJ•J� <br /> m 7 Transporter 2 Company Name S US EPA ID Number E� State TrpnspnrkeY <br /> CD <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number GY State Fact sty's 1D <br /> Z I UU")I KIAL ZIL-11 ICL U11_ GO, 111"44, a o Io I it 19 14 16 12 17 <br /> cc O 7(m S,'070- 4T H Focdtty;Phone <br /> Q 11 US DOT Description du <br /> on[endtng Proper Shipping Nglite,Hazard Class and ID Numbed 12 Containers 13 Total 14 Unit <br /> MY <br /> UNo Type Quantity Wt/Vol I Waste Number <br /> Z a s�� ��{{ y�r► l �r/�(,ry/�1 WARTF <br /> /-y9 r� State y Er <br /> i�ON-KCRA HA I'.r�iJti,Ji��8 n A 1 C I 10t)IL.} �G r <br />' G ; OILY X^dt".rEI' T r EPA/Other <br /> �. <br /> O N b State f r <br /> t <br /> v R EPAIOrher <br /> QT c State <br /> co O ah <br /> 1 R EPA/Other .f r r <br /> wd State <br /> Z ` <br /> U EPA(Otsex v <br /> LU <br /> ► tetra ?��ertal�J c►eS}J+Sava z }"� '"' �e � �4', L� KM>inndhRg"94 far 1Nastas Llalad AboveF i <br /> a ,'' r !✓ <br /> m f F x R` wwe - E a R r <br /> LUr- <br /> r1f <br /> Z 15 Special Handling Instructions and Additional Information <br /> 0 <br /> Z GLOVES <br />' LU LMERGENC:Y PH0N1< 20943691-68.67 <br /> J+ 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 packed <br /> Vmarked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations <br />' J <br /> � If I am a forge quontiy generator I certify that I have a program m place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes Ike present and future threat 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 Ike best waste management method that is <br /> Ce available to me and that I can afford <br />' }0 Printed/Typed NameSsgnature rt C f It}It Month Day / Yeor <br /> z rY ltf�ua L l��,uS�,r.l r lra t /1n1K f' Sr 1tJ /LU <br /> 0 T 17 Transporter 1 cknowleclgemenj of Fecet of Materials <br /> R <br /> A Panted/T a e Signature month Day Your <br /> LUP <br /> U- 0 18 Trans orter 2 Acknowledgement of Receipt of Materials <br /> —7 1 1 1 1 1 <br /> T Printed/Typed Nome Signature <br /> Iss Month Day Year <br />' E <br /> R <br /> V19 Discrepancy Indication Space <br /> Z A <br /> C <br />' I ns <br /> l <br /> I 20 Foci ityOwner or Operator Certification of receipt of hazardous materials covered 6Z this manifest except as noted in Item 19 <br /> T Panted/Typed Name Signature Month Day Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE <br />' DTSC 0 [1/991 <br /> EPA 87700-0-22 Yellow GENERATOR RETAINS <br />