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State of California--Environmental Protection Agency.,, <br /> arm Approved OMB No.2050-0039(Expires 9.30.991 See Instructions an back Of,page 6. <br /> P 9 Department a Toxic Substances Control <br /> I <br /> lepse print or type`: Form designedlpr use on efire,�,12•pith)typr `ger' Sacramento,California <br /> UNIFORM HAZARDOUS' 1.�ator's US EPA ID No. Manifest Document No. 2.2. Page 1 Information in the shaded areas <br /> WASTE MANIFESTof <br /> 1 is not required by Federal law. <br /> I(A)10111 t �J <br /> _ 1 3 <br /> 3. Generator's Name and Mailing Address { A: Stale Mo.nifest Document Number 6107 , <br /> B. State Generator's!D <br /> G .,Y <br /> A. Generator's Phone oc�Lty1 r <br /> 17. <br /> 5,;Transparier 1 Company Nome 6. US EPA ID Number C. State Transporier's 1D[Reserved.) <br /> Q f4ftelE-PIt'•.AN 4�ALLFY WAS TE 01l,, D. Transporter's Phone <br /> 7. Transporter 2 Company Name 8r'U$EPA ID Number E,,State Transporter's f0[Reserved <br /> F. Transporter's Phone <br /> 9. Desi naiad Facili Nome and Site Address 10. US EPA ID Number G. Slate'Facili 's ID <br /> 53tt � LAf„fS f`SOAU H. Facility's Phone <br /> RIVERE—IANK, CA 95367 <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and iD Number) 12• Containers 13. Total 14. Unit <br /> No. Tye Quantity WWI f, Waste.Number _ <br /> a. <br /> State <br /> It N-1`7GI �t HAZARDOUS) tRr��a'� f,,I. 1UIi T`2 <br /> G 1 00 Y %VATF=F? l:- EPA/Other <br /> Nb. !00 Slate <br /> ao E <br /> R EPA/Other ' <br /> 1A <br /> T Ssaie. <br /> o <br /> R EPA/Other' <br /> FAdditional <br /> State <br /> V <br /> EPA/Other , <br /> w <br /> . Descriptions For Materials listed Above K. Handling Codes for Wastes Listed Above' <br /> 15. Special Handling Instructions and Additional Information <br /> It. GLOVES <br /> t-t-MlrRGE ICY (HONE 209-66-r-885-1 <br /> Q16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper stripp ing name and are classified,packed, <br /> V marked,and labeled,and are in all respects in proper condition For transport by highway according to applicable international and national government regulations. <br /> ;lf I am a large gvantity 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 economically <br /> �Facticable and4hat I have selected the practicabfe method of treatment,storage,or disposal currently available to me which minimizes Ike present and future threat to human health <br /> aihd 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 /> rnld/Tpocl <br /> vailable to me and that I can afford. <br /> Name /A s �fif�r f� Signatvr�,,, � �r /" Month Day Year <br /> I I-al <br /> 0 T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> Printed/Typed e <br /> R YPd Nome Signature Month Day Year <br /> P ' r 1 <br /> 0 18. irons oder 2 Acknowledgement of Reef'`t of Materials <br /> RLLJ E Printed/Td ed Name <br /> T YP / Signature Month Day Year <br /> R <br /> 19. Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> ' f 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Printed/Typed Num* Signature Month Day Year <br /> 1 DO NOT WRITE BELOW THIS LINE. <br /> -TSC 8022A (1/991 <br /> �A 8700-22 Yellow: GENERATOR RETAINS <br />