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See Instructions on back of page 6. <br />Form AprovedtOP 8 No. 205090039 (Expires 9 -30 -(12 -pitch) <br />9) p typ ;, (� 9 .. r � ,,.,"vrDepatiment of Toxic Substances Control <br />Please print or e. Form designed for use on elite 12- itch) ewriter. ' $gcfo'Denloq falifwnio <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) <br />i EPA 8700-22 Yellow; GENERATOR RETAINS <br />enerotor's US EPA ID No. Manifest Document 1 <br />2. Page 1 <br />Information in the shaded areas <br />' UNIFORM HAZARDOUS <br />MANIFEST <br />❑ r� i C' ra � I <br />i � <br />is not required by Federal law. <br />WASTE <br />� Li <br />0 <br />of <br />t <br />3. Generator's Nome and Mailing Address <br />A. State Manifest Document Number <br />~�!t RLtiT�Tr1�l, L) <br />QR <br />+, <br />9774 <br />232 5 W . CHARTER 14AY <br />B. State Generator's ID <br />S'(t)(711'ON CA 1452 Hb <br />4. Generator's Phone (K, q 467-049V) f � *)F-11 N)X .15 ) <br />5. Transporter 1 Company Nome b. US EPA ID Number <br />C. State Trans porter's ID [Reserved.] <br />P R I I 11'3 E N V I R O N i 1 E N T AIs C A 1, :r 35 1 "I ?$ 1) 3 8 <br />D. Transporter's Phone <br />I <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID [Reserved.] <br />F. Transporter's Phone - <br />9. Designated Facility Nome and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />C)E24I`;NNO KF• Ji fR)()N <br />H. Facility's Phone 330—.5:3"1-71120 <br />2WItO N. ALAE{EDA S'CRIIE,P C A 3' tai !? 0 t? 1 :3 3 K 2 <br />CY)M ro t,I, CA. ",0222 <br />11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number[ <br />12. Containers <br />13. Total <br />Quantity <br />14. UnitNo. <br />Wt/Vol <br />1. Waste Number <br />Type <br />a <br />State <br />1`10N—RCRA 1-fAZARDOUS 1'FA8TI3 LIQUID <br />C, <br />ff <br />2:)3 <br />/Ofher <br />EPAMMy-)NE <br />b. <br />State <br />E <br />' <br />EPA/Other <br />R <br />A <br />T <br />C. <br />Stare <br />O <br />EPA/Other <br />R <br />d. <br />, <br />State <br />EPA/Other <br />I. Additional Descriptions For Materials Listed Above <br />K. Handling Codes for Wastes Listed Above <br />a1 0110 V -ASH :t1"$ii <br />C. b. <br />c. <br />d. <br />15 Special Handling Instructions and Additional Information <br />SENCt ?i HANIF'EST COPY, CD &: 200 PINE AVENUE <br />INVOICE — TO : WENDY J'ACOBUS : SUITE 51.4 <br />11 111 '\ <br />1 6. GENERATOR'S �C TIFICATION I hereby declare rhos the contents of this consignment are fully and accurate)yy described above by proper shipping name and are classified, pac ed, <br />marked, labeled, in in For transport by highway to international <br />and and ore all respects proper condition according opplicable and national government regulations. <br />If I am a large quantity generator, I certify that I have,o program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />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 <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 />to me and that I can afford. <br />lavailable <br />Printed/T ed Name <br />SignatureMonth <br />Day Year <br />T <br />17. Transporter 1 Acknowledgement of Receipt of Materials / <br />R <br />A <br />R <br />Printed/Typed Name <br />y .— - - �.-_' r <br />Sig�tlrre, r —�_.� ., <br />Month Day Year <br />P, <br />7 <br />0 <br />18. Transporter 2 Acknowledgement of Receipt of Materials - <br />T <br />Printed/Typed Nome <br />Signature <br />Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />1 <br />20. FacilityOwner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />T <br />Printed/Typed Name <br />Signature <br />Day Year <br />Y <br />TM <br />DO NOT WRITE BELOW THIS LINE. <br />DTSC 8022A (1/99) <br />i EPA 8700-22 Yellow; GENERATOR RETAINS <br />