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State of California—Environmental Protection Agency Form Approved OMB No.2050-0039(Expires 9-30-99) See ii Structioni; on pack ' 1Qe Department of Toxic Substances Control Pleaserprintor type. 'Form designed for use on elite(72-pito rifer. Sacramento,California 1. venerators US EPA ID No.: Manifest Document No. 2. Page 1 Fnformation in the shaded areas UN ORM HAZARDOUS not required by Federal law. WASTE MANIFEST A 3 Generator's Name and Mailing Address I `•�� _ c A. State Manifest Document Number IL-la\: 1_ "1 v.'.:: B. State Generators ID LO LO A. Generators Phone 0 y ) t1 4 Z . 3;_G E ti cV 5. Transporter 1 Company Name 6. US'EPA ID Number C. State Transporters ID Reserved.] LO -7 1, 5 L. _D. Transporter',Phonp 7. Transporter 2 Company Name n 8. US EPA ID Number E'..State Transporter's.ID[Reserved.] Q t: P'+ I!- I D 16 13 r , -F_Transporters Phone ... 9. Designated Facility Name and Site Address 10. US EPA ID Number F G State Facility's ID d Zc is - 0j ,' '-3 1 _ ` .af O H.-Facility's Phone (( 1 ac Af J U C� ' J ;^� Ci -� — 1 ..Z:7 _ 3... J ,t Q11. US DOT Descri mcludin Pro er Shi Name,Hazard Class,and ID Number 12. Containers 13. Total 14. Unit tton ' U p ( g p Skipping g ) No. Type Quantity Wt/Vol C Waste Number a' 3.NGt� c.Cl t't , I7!� 1'1laPUVS (SS`s i.i.� aal� 6+'T State _ G ..�. -� a EPA/O,her N E 4: d f - t+ i4 19 4-1 ! O N b' I State ago E N R EPA/Other v A c. O T State Co O R I I EPA/Other LU d. F- State _ Z U I EPA/Other fu 'r 0 { J. Additional Descriptions for Materials Listed Aho e FKHcmc1In9 Codes for Wastes.:1is:fe:dAbov=�rLU C Q Z O 15. Special Handling Instructions and Additional Information Q �:k..).i�,uS'*%: vM�F1tZ Aa!`i£'T.r'li�+•tc;?v% U K'ei. y-.. . - Z t'a'ts f^'..�,i Al L't t. W 7, :.a i^d 1 'n. ` :'S-i:Pei �:, I tki+.. :\F f Y UtJ• C;'� >�' `1 4 �.� 1%A G _ _. ar. roiRth?i. rt ':;'rt :'iia bird Lid(Z)+,_ ` !} [qc ! YviS'� C7~..p•q 16. GENERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified,packed, Q marked,and.la6eled,and are to all respects in proper condition for transport by highway according to applicable international and national government regulations. U 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 a- 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 O 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 available to me and that I can afford'. f1 PrinlgdyTyp_ed Name t I SignatureY 1' i' Month Day Year R17. Trans orter 1 Acknowled Acknowledgement of Recei t of Materials E A Printed/Typed ed Name 1 LU YP Signature - fl .. _ ] fi % Month Day Year tl� P '� I` .`�:?:U l�J;� }j:£ 1-1 f lr'I .✓;,..,0' - / `t' W 8 18. Transporter 2 Acknowledgement of Recei t,of Materials :F T Printed/Typed Name Signature, its. j Month Day Year LU E Qom✓ U 19. Discrepancy Indication Space - Z F A C L ��— t 1 20.iFa cillty Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. 'ri f ted%Typed Name w r / r t / Signature f^• Month Day Year - DO NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A(1/99) (Generators who submit hazardous waste for transport out-of-stale, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)