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ate of California—Envieonmentoi Protection Agency —10
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<br /> m Approved OMB No.2050-0039 lExplre5 9-30 991 See Instructions an back age f3. Department of toxic Substances Control
<br /> ease print or type. Form designed for use on elite 112-pitch� 'iter. Sacramento,California
<br /> 1- Generator's US EPA ID N0. on,e$t Document No, 2..Page 1 Information in the shaded areas
<br /> UNIFORM HAZARDOUS I is not required by Federal low.
<br /> WASTE MANIFEST 64 (, ,! t / !- a
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<br /> ad Mailing
<br /> 3. Generator's Name nAddress _'h jj F A.`"'Sinlrl
<br /> te ariifesl Dbturtiertt-Num_ber f -p
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<br /> A. Generator's Phone l
<br /> F. 5. Transporter I Company Name 6- US EPA ID NumberC k:5fatertt'.anspor(ers'I11-�f?{Reserved:] -``"^" ��•_ ` .` .`
<br /> J i � E> transparterrs Phone V a f
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<br /> 7. Transporter 2 Company Name I 8. US EPA ID Number 1 EF State 7ran4p°rter x f [Reserved;] *
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<br /> 9. Desi gated Facility10.Name and Site Address US EPA ID Number G:'S1pte fptslr 3 ID iI
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<br /> . " 12. Containers 13. Tutal IA, Unit
<br /> t 1 1. US DOT Description lincluding Proper Shipping Name,Hazard Class,and ID Number) ., x• .fir
<br /> y; No. Type Quantity Wt/Vo€ I,,Vsraste'Nvmber `a�.8 ;z
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<br /> J E`0.ddihonol=f3escrFptrans far lctfarlafs€fisted Above ', ,°ate ..g` aad€rng Codas foF,Wasted Eisted Above.
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<br /> J 15. Special Handling Ipnstructionspnd Additional Information
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<br /> 16. GENERATOR'S CERTIFICATION: I hereby declare rthat the contents of this consignment are fully and accurotely described above by p�6pelshipp�ing name and are classified,/packedl- _
<br /> Q marked,and labeled,and are in oil respects in proper condition for transport by highway according to applicable international and national government regulations.
<br /> If I amp 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 economicoily
<br /> practicable and that I have selected the ppracticable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to humor health
<br /> and the environment;OR,if lam a small quantity generator,I have made a good faith effort to minimize my waste gereration and select the best waste management method that is
<br /> available to me and that.I can afford.
<br /> Pr6nledfT"`ff Name :' Si nature'•/ y. Month Doy Yea /
<br /> uA T 17. Transporter 1 Acknowledgement of Receipt of Materials
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<br /> e-cr, A Printed/Typed Name Signore�r - Month.. DayYear
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<br /> O 0 18. Transporter 2 Acknowledgement of Receipt of Materials
<br /> R Printed/Typed Nome Signature Month Doy Year
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<br /> } 19, Discrepancy Indication Space
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<br /> 20. Facili[Z Owner.or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19.
<br /> T Printed/Typed Name Signature Month Day Year
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<br /> DO NOT WRITE BELOW THIS LINE.
<br /> F]TSC 8022A I}/99) Yc lour: GFi-lFRATOR E' -.'d5,
<br /> ?PA 8700-22
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