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oraI Protection Agency
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<br /> UNIFORM HAZARDOUS 1• Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> WASTE MANIFEST is not required by Federal law.
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<br /> 3. Generator s Name and Mailing Address A. Stare Manifest Document Number �)y
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<br /> LO ° , fsjtda; ii,jF�; B. State Generator's ID -
<br /> • 4;'Generator's Phone ( .'_i!li ).;:ii 7..; ,,,:
<br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved]
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<br /> .., 1 _ D. Transporter's Phone
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<br /> 00_ 7. Transporter 2 Com an Name
<br /> P P Y 8. US EPA ID Number E. State Transporfer's ID[Reserved:]
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<br /> Q � F. Troqq)orfer's Pho�e
<br /> nu 9. Designated Facility Name and Site Address 10. US EPA ID Number G. Stade I.ty' ID / qqy/
<br /> O H. Facility's Phone
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<br /> Q US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number 12. Containers 13. Total IA. Unit
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<br /> No. Type Quantify Wt/Vol I. Waste Number
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<br /> V) J-/A it ql Descri tions for tenals Lista Above K Handling Codes F Wastes Listed Above
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<br /> Z 15. Special Handling Instructions and Additional Information
<br /> O 771E REFERENCED WASTE WAS,.�C � 1XD1 Fp? ST . R§1,�1sE r�QFES{
<br /> Q DISPOSAL.TREATMENT OR RE1tSE CIY�HY'b' `fl �M1C�((PERrt1F�fTI FLI1ffY`tIN1J�1�' ;i t
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<br /> w `FI 1 MA aa'< C;i [o k,: W 17 THE EKVptONhT AL PROTECTION A'' ( W"��Q�Q�NCT W(1}{'1}�p-40V.11SlONS.
<br /> 2 711E RESOURCE CONSERVATION AND REC�VfRY'ACi"f7F 1976"1'OGEI}�R WE(Tf APPLIMg1 4!
<br /> 16. GENERATOR'S CERTIFICATION: I hereby decld e'on thj}&p ��fy q - _ wame and are classified,packed,
<br /> Q marked,and labeled,and are in all respects ino0e0prdyR&1jpn for transport by highway actor ing to applicable inter notion. and ndtion6l"government regulations.
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<br /> J If I am a large quantity generator,I certify that 1 hove a program in place to reduce the volume and toxicity of waste generated to the degree 1 have determined ro be economical)y
<br /> N practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the Qr�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 sele;mst waste management method that is
<br /> available to me and that I can afford.
<br /> Printbd7(Typ�d Nam l SignafVre!% ^ G�? ^O Month Day Year_
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<br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials +
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<br /> W A Printed/Typed NameSignature % f / Month Day Year
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<br /> w 0 18. Transporter 2 Acknowledgement of Receipt of Materials
<br /> R Printed/Typed Name Signature Month Doy Year
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<br /> U 1 Discrepaqncy Indication pace ` t
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<br /> l 20. Facility Owner or O en 6Ftertification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name` iZSignatures`+ ` (vlogl(( Dq*-, Year
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<br /> DO NOT WRITE BELOWT�HIS LINE.
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<br /> F $ENDS THIS COPY TO GENERATOR WITHIN 30 DAYS,
<br /> DTSC 8022A ]1/99) ( nerators who submit hazardous waste for transport out-of-state,
<br /> %,�P7i.'"Bry�410-22 �� completed copy of this copy and send to DTSC within 30 days::):.
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