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State of California—Environmental Protection Agency <br />'Fs3rm A d OMB No 2050-0039(Expires 9 30 991 See Instructions on back of page 6 Department of Toxic Substances Control <br /> P r nt r type Form designed For use on elite 112 pitch)type-=ter Sacramento California <br /> UNIFORM HAZARDOUS 1 ator's US EPA ID No Manifest Document No 2 Page 1 Information in the shaded areas <br /> is not required by Federal law <br /> WASTE MANIFEST (� j ? !I �" of I <br />' 3 Generator s Name and Mailing Address 1014 PON(A WO C6KFA State Manifest Document Number <br /> '4cx�q s.Ei C)oRodo 2373361 <br /> O lz—I —t""�Ig f+, C�p v B State Generator s ID <br /> 4 Generator s Phone {. l � ] 109 c fCl F+ t� l �(,Q T <br /> 5 Transporter 1 Company Name 6 US EPA ID Number C Stale Transporter s ID[Reserved <br /> ''��+�I-Rt�'r'A� VA i EY ` S i E 0`- 0 AL � Q � L' '� 7 �* 7 3�4 0 Transporter's Phone <br /> r <br /> 7 Transporter 2 Company Name 8 US EPA ID Number E State Transporter s ID[Reserved] <br /> QI I I IF Transporters Phone' <br /> 4U 918poll lki hqk NZ ftc1i APk1!4 W—R 10 US EPA ID Number G Stat9jFacs y s ID � tl wl b <br /> ,s�1' 300 rwLALi,14 R AQ H Facility s Phone <br /> 1nt <br /> 11 US DOT Description Coainers 13 Total 14 Unit <br /> ption(including Proper Shipping Name Hazard Class,and 1D Number) No Type Quantity Wt/Vol I Waste Number <br /> z <br /> a NON € ONA HAZA><l2DOU9, WAet;rF 1.1gUIP state ,121 <br /> G j 0; Y WAT LR 0 0 1 T I 9 a EPA/Other <br /> E b stare <br /> N <br /> m E <br /> R EPA/Ocher <br /> T <br /> T <br /> State <br /> co O <br /> R EPA/Other <br /> d State <br /> V EPA/Dther <br /> LU <br /> J Additional Descriptions for Materials Listed Above . K Handling Codes for Wastes Listed Above <br /> tip" <br /> C fLY WATER 01 b <br /> LU <br /> °L c d <br /> J <br /> 15 Special Handling Instructions and Additional Information <br /> < �.LOVC <br /> ZEMERGENCY PHONE 209 067 CIA57 <br /> 16 GENERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified pocked, <br /> Vmarked and Ia6eled and are in all respects in proper condition for transport by highway according io applicable international and national government regulations <br /> If I am a large quontiy generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determmed to be economically <br /> practicable and that I hove selected theracticable 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 /> a[ ovadc166 to me and that I can afford <br /> O <br /> Printed/[y a Name Signature,.] i 1onth Day Year <br /> B17 Transporter I Acknowledgement of Receipt of M tenals <br /> LU p Printed/Typed Name {"^ `yWE/� /aft f✓' Signature r Month JJDay/ YePy <br /> 0 18 Transporter 2 Acknowledgement of Recei i of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> usui E <br /> R <br /> F 19 Discrepancy Indication Space <br /> A <br /> C <br /> LI 20 Fac le Owner or O erator Certification of recei l of hazardous materials covered by this manifest except as noted in Hem 19 <br /> Printed/Typed Name Signature Month Day Year <br /> DO NOT WRITE BELOW THIS LINE <br /> ,SC 8022A (1/991 <br /> PA 8700-22 Yellow GENERATOR RETAINS <br />