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State of Cohfornio—Environmental Protection Agency <br /> I <br /> Form Approved OMB No 2050-0039{Expires 9 30 99) A See Instructions on back of page 6. Department of Toxic Substances Control <br /> Please print or type Form designed for use on elle f 12 p+tc f•^ewrder Sacramento California <br /> Anerator's US EPA ID No Manifest Document 2 Page I Information in the shaded areas <br /> UNIFORM HAZARDOUS A L u U p 17 t '7161I , j is not required by Federal low <br /> WASTE MANIFESToA <br /> 3 Generator s Name and MoilingAddress umfseFi 9.8 �4%1 .0-001 0 o <br /> Gu�e�'Lumb "/'}!� <br /> as S ' -Cura C1 o �T <br /> 0 �t 1 t ``N�v V <br /> 4 Generators Phone{2 i./+\ 1f �„'� F tt 'v .� iy a <br /> 5 Transporter I Company Name 6 US EPA ID Number mS agelfk� p &yr a t "; <br /> as <br /> RnAtrtSinwuY llAss 4F 1srH <br /> etsa_rrsvrasrt rK1 4�s rrM4.`sT —. 4IL 1 ry J z 7hU 7 C ` <br /> 7 Transporter 2 Company Name 8 US EPA ID Number rls r r1s '' <br /> Q ' <br /> V est at F liry Na e a Sita Addr ss 10 US EPA ID Number G t tp aei y' tD a �< <br /> N u a� �'..iLUJCR, OIC <br /> to <br /> I 1 US DOT Description(including Proper Shipping Name Hazard Class,and ID Number) 12 Containers 13 Total 14 VolUni <br /> P f g P pP g No Type Quantity Wt/Vol I Waste Number:, <br /> a State a ; <br /> = Nf)Ir}..RCRA HAZAROMS WASI'F i.IQIA@ i X23 <br /> t 3 G ; OILY WATER ', 00 1 r T a Y EPA/Other� x � <br /> N b State <br /> co I <br /> R EPA/C11ha �`" <br /> T c Stale z <br /> T <br /> as 0 EPA/plh c" <br /> R S <br /> d � State <br /> lJ Y EPA/Other <br /> LU <br /> l_Ad tbqf�hc �fc�ple4s�dHandling Dada"sor Wostas fisted Above t <br /> 15 Special Handling Instructions and Additional Information <br /> Z <br /> z GLOVES <br /> EMERGE-NCY PHONF 2"-667-8857 <br /> 16 GENERATOR'S CERTIFICATION I hgreby declare toot the 4ont9nts 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 prep$cotldition for transport by highway according to applicable internahonal and national government regulations <br /> IF I am a large quantity generator,I certify that i hove a program in 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 the 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 the best waste management method that is <br /> available to me and that I can afford <br /> O <br /> Printed/Typed Name $ r b r 5ignatur Month Day �)(ea= <br /> r ' �� <br /> tu, T 17 Transporter 1 Acknowledgement of Rec i I Mal cols <br /> A <br /> APrinted/Typed Nam Signature nth <br /> R ay� ar <br /> KS <br /> P <br /> B 18 Transporter 2 Acknowled amen)of Receipt of Materials <br /> 7 T Printed/Typed Name Signature MoQlh Day Year <br /> E <br /> II <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br />' I <br /> L <br /> l 20 Facility Owner or Operator Certification of recei t of hazardous materials covered bX Phis manifest except as noted in Item 19 <br /> Printed/Typed Name Signature Month Day Your <br /> ' DO NOT WRITE BELOW THIS LINE <br /> I Yellow GENERATOR RETAINS <br />