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Slate of Cahtornio�Environmental Protection Agency <br /> Form Approved OMS No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or type form designed for use on elde(12 prick)ty r s�1 Sacramento California <br /> - 1 ator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> UNIFORM HAZARDOUS f is not required by Federal law <br /> WASTE MANIFEST L U tip of <br /> 3 Generator s Name and Marling Address LAonna <br /> l7 r t J tj A Slate Monlf eat Document Number <br /> S:V ! `22,9686-1 <br /> ' � _� d Q rr �, �.- <br /> �`/� / a�..^y�+�,� fl/', 8� StalarGenerator's ID " � �^�v- <br /> U"11— ���r/ �i� l{� !\ l 3J !wr_040 <br /> 4 Generators Phone ' �' � �y ✓ ._. ' ��� - -� c,�`T <br />'tV 5 Transporter 1 Company Name 6 US EPA ID Number C'State Transporter's IDto <br /> 00 <br /> o AMEP11;f1s''sf VAI 1 V_'v '1 .A7 ZTf' 0r!~ $ # PI (1 s"i R I 7 3; 1 ki D {Tronsporter'sPhone <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter's ID]Reserved <br /> U F Tra_n'sporler s Phone," <br /> Q e t��� r 10 US EPA 1D Number <br /> Q k1RpmI folk iJi�.'.. �r . 14iV;5�ir" !"ate 5tafp fa rl� lb0 {,s_0,,ri'V re <br /> V V I A� ';7 <br /> Z 5 M O Ot ALJA ROAD H Facility s Phone' <br /> O hilt ERBA NK, OA 95367 IAII U C1 Q 1 9 1018116 209.803-818 <br /> 12 Containers 13 Total 14 Un I ,t v >F <br /> Q 1 I US DOT Description lincludsng Proper Shipping Name,Hazard Class,and ID Numbers qt a <br /> No Type Quantity Wt/Vol I Waste Number" <br /> ° NON-RCCA HA7ARDOU0+ WASTE. I_!QL� D Staten <br /> G <br /> ( OILY WATER ) ik 0 1 T €' Cs EPA/Other <br /> IE.Q E b state <br /> ao t, <br /> ao E <br /> R EPA�Other <br /> IC14 <br /> A stateV <br /> o T <br /> 00 o _ <br /> R EPA/Other <br /> r ` ' d <br /> u . fPAJthei� t <br /> w <br /> sJ tAddittonol Descriptions for Materials Listed Above"' ' _ K Hondlmg"Codes for Washes Listed Above ^w <br /> OILY-WATER ', `_; ';° fir w _ y,14 <br /> � x 4 E r T �. i � � � � r a -r 4 � • �''l T e d ;d, -.Zy _ 1's`-` <br /> �� •• } i� r � r S <br /> Q15 Special Handling Instructions and Additional Information a <br /> a Ck UVr-,Ty <br /> Z EMERGENCY P110N(_ 209-66 7 l;7 <br /> L! 16 GENERATOR'S CERTIFICATION I herebydeclare that the contents of this consignment are full and accurately described above by proper shipping name and are classified,packed <br /> Vmarked,and labeled and are in all respcts in proper condition for transport by highway according to applicable international and national government regulations <br /> If I am 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 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 /> O <br /> available to me and that I can afford <br /> Printed/T ped Name Signoture r r 1 r Month Day Year <br /> Z <br /> _f <br />'[ie ! <br /> w T 17.T(oris orter 1 Acknowledgement of Receipt of Materials <br /> Year <br /> Cie <br /> A Print /Typed Name Signature ] f Y ) <br /> w P 1t t t ! 4 V�" _, i, 1 a✓ <br /> LL_ p 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> 0T Printed/Typed Nome Signature Month Day Year <br /> w E <br /> R <br /> V� F 19 Discrepancy Indication Space Z <br /> A <br /> C <br /> I <br /> 1 20 Facility Owner or O erator Certification of receipt of hazardous materials covered by this manifest exce t as noted in Item 19 <br /> �j Printed/Typed Nome Signature Month Day Year <br /> 1 <br /> ' DO NOT WRITE BELOW THIS LINE <br /> DTSC 8022A 11/99) <br /> EPA 8700-22 Yellow GENERATOR RETAINS <br />