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State of California—Environmental Protection Agency <br /> arm Approved OMB No 2050-0039[Expires 9 30 99) See Instructions on back of page 6 Department of Toxic Substances Control <br /> lease print or type form designed for use on elite(12 pitch)ty- -,ter f Sacramento California <br /> ��il <br /> l�erotor's US EPA ID No Manifest Docu ant No \ 2 Page I Information in the shaded areas <br /> Q C,�0 4. -� is not required by Federal low <br /> of 3 ess fR� �� / / I '• A State Manifest Document Number �q p4 r9 p+4 ,p } <br /> f + iii► '�t�Ii •�r+�r 3 4 if <br /> C> r _ t,�_ w ,� B State Generator s ID ' <br /> 4 Generators Phone It�r ) tr �✓ i '�'t o <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C State Transporter s ID[Reserved] <br /> p A&11:_RiCAN VAI-L&I-Y YVAL rOIL a: A 4, 0 U 0 �3 2 { 1 7X D Transporters Phone <br /> I <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] _ <br /> N � <br /> F Transporter s Phone <br /> Vli 1e d�r $mesa s 10 US EPA ID Number G StptgA foci ry ID <br /> AUS R0,A <br /> H Facility s Phone ' <br />►Q 10 tr`EtR11ANAK (,`rA D5,16 e r,i A LiQ'i0i0ilia 081 11 F3 20 -:e"I'l I <br /> U_ <br /> J 12 Containers 13 Total 14 Unit <br /> 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) No Type— Quantity Wt/Vol I Waste Number <br /> a MON 0,RJ\I-Tf,7AI�ID YlJ. '; WaSTr L9 013K., stare <br /> O r \ / ' EPA/Other <br /> E b C <br /> N State 1 <br /> 65 R EPA/Other <br /> A [ <br /> T c state <br /> O <br /> R EPA/other <br /> d State <br /> EPA/Olhar 1 <br /> V k <br /> LU <br /> J Additional Descriptions for Materials Listed Above K Handling Codes for Wastes Listed Above <br /> i 01 WAIh.R a a 01 b II <br /> LU n i <br /> a' c d <br /> J � <br /> 15 Special Handling Instructions and Additional Information <br /> Z <br /> 16 GENERATORS CER71FICATION 1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are clo"ified packed <br /> tat marked and labeled and are in all respects in proper condition For transport by highway according to applicable international and national government regulations <br /> if I am a large quantary 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 /> available to me and that I can afford r <br /> O <br /> Printe8/Typed'N9me Signature jr�xy'+° _ _ f� , t Month Day Year <br /> 0 p <br /> T 17 Trans orter 1 Acknowledgement of Receipt of Materials <br /> wA Printed/Typed Name Signature / anfh Day Year <br /> S r <br /> P <br /> 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E T <br /> � R <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 by this manifest except as noted in Hem 19 <br /> Printed/Typed Nome Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> I <br /> I <br /> DT5C 8022A (1/99) Yellow GENERATOR RETAINS <br /> IPA 8700-22 <br /> E <br />