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State of California-Environmental Protection Agenry <br /> Form Approved OMB No.2050 0039(Expires 9-30-99) <br /> Please print or type. Form designed for use on elite(12•pitcl srfer. See Instructions on back 0 <br /> ge 6. Department of Toxic Substances Control <br /> 1. Generator's US EPA ID No. Manifest Document No. 2.2M..-41 <br /> Information a in the shaded of eas <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST ot required by Federal law. <br /> FF. <br /> enerator's Noni-9 and Mailing Address ' <br /> fir+ A. State Manifest r �„ �y�, t,LO <br /> r . a r # t ,,b;, B. State GeneratorGenerator"s Phone(N 5. Transporter 1 Company Name6. US EPA ID NumbermC. State Transporte ]O ]f:ri. D. Transporter's Ph <br /> CP7. Transporter 2 Company Name 4�9—x.390 <br /> 8. US EPA ID Number E. State Transporter's ID[Reserved,] <br /> aFu.} J <br /> J <br /> UF. Transporter's Phone <br /> 9. Designated Facility Name and Site Address G. State Facility's ID <br /> 10. US EPA ID Number <br /> • d ;:;:.:,:x' t. ,:1?"Ll:'I't'sf� <br /> 4 Z f+r.:.:r W.. !?']`lei 8T. Df D 6 4 p D 1 9 <br /> m Z 7y <br /> M 0 7.e4.:V14 6 8.���CH,, CA ` 081..3 1 „f ,s , � H. Facility's Phone <br /> y�4 562)4 12-54 <br /> UUS DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) 12. Containers 13. Total 14. Unit <br /> Z a. y y� r r r_ No. Type Quantity Wt/Vol I. Waste Number <br /> _ a _1..1 i' (: L IIfl AA M.Al 13 <br /> t= Y,l y < State „)q <br /> 1.1 <br /> Ci R4�R f) s !V f'' f� ��' EPA/Other., <br /> G I <br /> o E +N fib. ,���+`s' fd4A bF d;�'r %' �� yg i�f <br /> co "' a L•"`�(0 !L' State <br /> 00 R q F° o, ' f fi4 X ,L <br /> C14 <br /> A ) { � js EPA/Other /A <br /> c. <br /> 00 O $fate <br /> R <br /> 1 :> R?C ;t'Z) i.�; EPA/Other <br /> Z -1— <br /> State <br /> y; I <br /> w ?,, nCts{T TT IL TCEFFYEN, iFOSGY (t tq [ EPA/Other <br /> 1c <br /> L0 J. Additional Descriptions for Materials Listed Above <br /> Z a H {r8]!Lbc$&r Wastes Listed Above <br /> Q <br /> L 1Xi 'S <br /> cn , ` b' <br /> 9 yt4Z3 (d x°° 'dz� l SSp iris,LU <br /> CA 95252 <br /> QC. d. <br /> 0 15. Special Handling Instructions and Additional Information rti 6• <br /> Q •• <br /> �..,:' :?+;.:�' At`4� ._'j4�`iS�•.?tw.;., F'�� t i.'=". ]�tY; €�:�?;1 i.;:`�4� 1'i` <br /> LU ' <br /> —J+ 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,packed, <br /> Q marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> V <br /> J <br /> 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 <br /> N practicable and that 1 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 /> W available to me and that I can afford. <br /> O <br /> - - <br /> V Printed/Typed Name t Signature Month Day Year <br /> LJ.I �.✓ <br /> RT 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> LU p Printed/Typed Name r <br /> N dam^ Signature :- v„yy J Month �a�y� Year <br /> w P ,r�fLt>3:' @, r 9i yd:F{ <br /> ur 0 18. Transporter 2 Acknowledgement of Receipt of Materials <br /> 0 R <br /> E Printed/T d N <br /> LU yPeName Signature Month Day Year <br /> Q R <br /> V 19. Discrepancy Indication Space <br /> Z F <br /> — A <br /> C <br /> I <br /> L <br /> 1 20. Facilit Owne'r'or O erax r Certification of receipt bf hazardous materials covered 6 this manifest exce t as noted in Item 19. <br /> T Printed/Typed Name F " Signature. <br /> J, Month. Day Year <br /> DO NOT WRITE BELOW THIS LINE. <br /> Yellow: TSDF SENDS THIS 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 produce completed copy of this copy and send to DTSC within 30 days.) <br />