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Siete of California—Environmental Protection Agency <br />'Farm Approved OMB No 2050-0039(Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type Form designed for use on eirte f 12 pitch) rilar <br /> Sacramento California <br /> UNIFORM HAZARDOUS ' generator s US EPA ID No Manifest Document 11, _ 2 Page I Information in the shaded areas <br /> WASTE MANIFEST L L r ( r U 00 <br /> s not regwred by Federal low <br />' 3 Generator s Name and daihng Address r A State Manifest Document Number <br /> �" � r�� c4 �..� 09645220 <br /> 3 ; `1g 2 yv <br /> O B State Generator s ID <br /> 4 Generators Phone ['7� <br /> L <br /> { -�' } t� f i � � Y� � 5 � 'yL <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved} <br /> co <br /> •� i y u i v i i ! r t `co <br /> D Transporters Plane 500�73��4• � <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID fRelerved J <br /> 1� <br />`Q F Transporter s Phone <br /> 9 Designated Facility Name and Site Address 10 US EPA ID Number G State Facility s ID <br /> tit=,c t �r.r+lN �1. •, ftvi�_� <br /> JA1111 VI 1110161414 7 10131 <br /> H Facility s Phone ������ r <br /> 0F` t LJ .! , yr r • J r1 r� i 1,,,-9U43 <br /> iIii US DOT DescripLon(including Proper Shipping Name Hazard Class and ID Number) ,12 Containers 13 Total I4 Unit <br /> i <br /> No Type Quantity Wt/V01 I Waste Number <br /> a Stale <br /> NON , s r's. f,tt,'Awiii�ll}�S t<ylsyr:- f frtifi![r ,�`f� <br /> G e r_' '1' Y%"n 7 c F' r t' r 1 t �, EPA/Other <br /> E <br /> b <br /> N State <br /> co E <br /> R EPA/Other <br /> T ` <br /> State <br /> co O <br /> R EPA/Other <br /> 1 State <br /> LU <br /> V EPA/011ier <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes listed Above <br /> UiLY IsVA)L 8 a Ul b <br /> LU <br /> LU <br /> c d <br /> 15 Special Handling Insirvotons and Additional Informotion <br /> C L/4 qS ZO C <br /> 16 GENERATORS CERTIFICATION i hereby doctor&that Ike contents of this consignment ore Fully and accurately described above by proper shipping name and are classified packed <br /> Q marked and labeled and are in all respects in proper condition for transport by highwoy according to applitoble international and national government regulations <br /> If I am a large quanny generator I certify that I haw a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economicolI <br /> N practicable and that I hove 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 mode a good forth effort to minimize my waste generation and select the best waste management method that is <br /> x avmloble to me and that 1 can afford <br /> PJ tinted/Ty'pe`d Nam Si no r[e., -Xk �� nth 6,,y <br /> ser <br /> ^ t4 s1'i W n1LY^-� µµ1�Me �'V <br /> tL 1 17 Trons orter 1 cknowled eine Receipt of Materials <br /> 0. Printed) ped Na a Signature est pa C�U <br /> s 1 k �'�-c' r.1 �� Y <br /> P <br /> 6 <br /> IS Trans orier 2 Acknowlad ement of Recei t of Materials <br /> O R Printed/T ed Nome Signature <br /> F YPMonth Day Year <br /> LWR <br /> 19 Discrepancy Indication Space <br /> F <br /> A <br /> C <br /> I <br /> L <br /> 20 Facility Owner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19 <br /> ranted/Typed Name Signature Month pay Year <br /> DO NOT WRITE BELOW THIS LINE <br /> 1 <br /> r <br /> �C 0 {1/991 <br /> 87700--22 Yellc, GENE,tATOR RETAINS <br />