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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of I 6. Department of Toxic Substances ntrol <br /> PI riot or,type. Form designed for use on elite(12-pikhJ ty, .,ter. Sacramento,California <br /> UNIFORM HAZARDOUS 1. Generator'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 of <br /> 3 Generator s Name and Mailing Address A. State Manifest Document Number <br /> 33041 <br /> 2 93 <br /> O r' B. State Generator's ID <br /> LO <br /> 4. Generator's Phone <br /> N 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.] <br /> LO <br /> O �+ D. Transporter's Phone <br /> o <br /> 510)749.1390 <br /> 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.] <br /> � J <br /> t < F. Transporter's Pone <br /> r, <br /> 9 pgyatgn4tod Facil``ty,Ngqje and Site Address "'10. US EPA ID Number G. State Facility's ID <br /> `+ 30 �-3 1irl'P3 tzl,. <br /> O r ('k ii!j t; j H. Facility's Phone ?4 "55 <br /> fi J <br /> (aJ ,11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> No. Type Quantity Wt/Vol I. Waste Number <br /> a. r I e, 11;, State [ <br /> 2 _ <br /> � t <br /> G EPA/Oth f <br /> O N b. 1i: ! t f. ,t { t + State IfI <br /> oo E <br /> R EPA/Othef,CN <br /> CiO <br /> O T AA:.. - State I <br /> a0o O <br /> R EPA/Other•,>,. <br /> LU d. d�. ) f t :: State f <br /> LU ' n t`1'I J fi .lel a. <br /> V r - i. EPA/Other(A <br /> LU / <br /> ZJ. Additional Descriptions for Materials Listed Above J.te K. Handling Coded For Wastes Listed Above a. <br /> O' 54 L,. � f..0 ;.. �. b..? Ft `rr- <br /> . <br /> ?. .ty 3pri:nga, 9v�5W <br /> 11C) q?6J4 EJZA* 154 (t x5 <br /> + � :tz - ftl�5„t rp C. L d. <br /> J �(� <br /> Z 15. Special Handling Instructions and Additional Information E4; i,, +5+ 'y + r ry*+i F} ty;l•r�pyx {.art 1s F? T�”;j 7,' +%;µ-iy 4 t't+] €' <br /> Z _ . <br /> uu <br /> F <br /> 16��GENERATOR'S CERTIFICATION: I hereby declare that the cop)' q� isycene+gninentare Imlfyandaceurate y described above by proper shipping name an are`iIassiFied,packed, <br /> Umarked,and labeled,and are in all respects in proper cond'0i+�4Qf fr�ansp,ort-by:highway according to applicable international and national government regolgtions. <br /> A'ITH T'I It L' <br /> If I am a large quantity generator,I certify that I have a pr %m"�-rS$Wke!to'reduce the-volume and toxicity of waste generated to the degree I have determined to be economica11 <br /> practicable and that I have selected the practicable method 6&tMe,+f aFbrSge;lor disposal currenfly_avoilable..to me which minimizes the present.and Futurp;ihreat to human health <br /> N and the environment;OR,if I am a small quantity generatoiPGFdidPWniifde!•d§aa"d faith effortiairdnimize�+myLwoSt€iggwctlOti OW_si I.etl,jl e w ement method that is <br /> � lv P.#e;"14999 <br /> 0 available to me and that I can afford. ACCORDLNGLY <br /> } PMted/Typed Name Signature Month Day Year <br /> w T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU p Printed/Typed Name Signature Month Day Year <br /> R <br /> w 5 <br /> U_ 0 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> TPrinted/Typed Name Signature Month Day Year <br /> w E <br /> N R <br /> V19. Discrepancy Indication Space <br /> Z 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 ltem 19. <br /> T Printed/Typed Name Signature Month Day...,, Year <br /> Y <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow, TSDF SENDS TH15 COPY TO GENERATOR WITHIN 30 DAYS. <br /> DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, <br /> EPA 8700-22 <br /> produce completed copy of this copy and send to DTSC within 30 days.) <br />