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State of California—Environmental Protection Agency
<br /> Form Approved OMB No.2050-0039(Expires 9-30.99) See Instructions on bad page 6. Department of Toxic Substances ntra
<br /> Please print or type. Form designed for use on elite(12-p. typewriter. Sacramento,CaliFor i
<br /> UNIFORM HAZARDOUS 1• Generator's U$EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas
<br /> is not required by Federal law.
<br /> WASTE MANIFEST ;, fs t) 019 ? q of
<br /> 3. Gen rotor's Name and Mailing Address A. State Manifest Document Number
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<br /> `i 1 :7! .1.1r CA 9"��i.�3— 1.055 B. State Generator's ID
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<br /> 4. Generator's Phone( +'i ) t?�}P .I 096
<br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID[Reserved.[
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<br /> CP r rw TY z < D. Transporter's Phone
<br /> (510)'749-1390
<br /> CP 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID[Reserved.]
<br /> �'w a F. Transporter',Phone
<br /> U 9. Designated FacilityName and Site Address 10. US EPA ID Number G. State Facility's ID s �s
<br /> Q {.�tR.t�7T'iY F. F '+F�• '�'f 4� t.NC JCJAI D 01210141019101 1 :7
<br /> Z 1630
<br /> WIne , 17TH S` .
<br /> r H. Facility's Phone
<br /> t /� t �� 79 04 (562)4342-544S
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<br /> �Q 12. Containers 13. Total 14. Unit
<br /> yt 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number)
<br /> 'Qu n4 No. I Type Quantity Wt/vol I. Waste Number
<br /> Z a. State
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<br /> "LLJ YV) J. Additional Descriptions for Materials Listed Abovejut' nANL,
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<br /> N tt8 3y3"� 5 ! a�. tl�} (fv # Vallfov ,S'P.rirms, CA 95252 d.
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<br /> 15. Special Handling Instructions and Additional Information (fS€,. A PPROPOZ ATE I?f�Rt JS0NA1• PR(rI EC-7T•F,� rr,,CA IPM NT
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<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,packed,
<br /> Vmarked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> If I am a large quantity generator,I certify that I have a pr ram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically
<br /> a_ practicable and that I hove selected the rocticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health
<br /> N
<br /> and the environment;OR,if I am a sma I quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is
<br /> available to me and that I can afford.
<br /> OPrinted/Typed Name Signatule F'a._ Month Day Year
<br /> W T '1-7'Trans prier 1 Acknowledgement of Recei°t of Materials (' `✓
<br /> RSi nature -^ �'�"�' Month Day Year
<br /> W A Printed/Typed Name �^ 9
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<br /> LL. B 18. Transporter 2 Acknowledgement of Receipt of Materials
<br /> O T Printed/Typed Name Signature Month Day Year
<br /> W E
<br /> N R
<br /> taj 19. Discrepancy Indication Space
<br /> Z F
<br /> — A
<br /> C
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<br /> I 20. FacilityOwner or Operator Certification of receipt of hazardous materials covered b this manifest except as noted in Item 19.
<br /> T Printed/Typed Name Signature Month Day Year
<br /> Y
<br /> DO NOT VRITE'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.)
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